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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introdu&#231;&#227;o</span><p id="par0005" class="elsevierStylePara elsevierViewall">Hepatite autoimune &#40;HAI&#41; &#233; uma doen&#231;a hep&#225;tica inflamat&#243;ria cr&#244;nica e progressiva&#46; A HAI &#233; imunomediada&#44; caracterizada por altos n&#237;veis s&#233;ricos de aminotransferases e imunoglobulina G &#40;IgG&#41; e detect&#225;vel por autoanticorpos e comprova&#231;&#227;o histol&#243;gica de hepatite interface na aus&#234;ncia de uma etiologia conhecida&#46; A HAI &#233; uma condi&#231;&#227;o rara com incid&#234;ncia relatada de 0&#44;4 a 3 por 100&#46;000 crian&#231;as&#46; A HAI pode ocorrer juntamente com outras doen&#231;as autoimunes&#44; como diabetes Tipo I&#44; hipotireoidismo e l&#250;pus eritematoso sist&#234;mico&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">1&#44;2</span></a> A preval&#234;ncia da HAI&#47;s&#237;ndrome da sobreposi&#231;&#227;o com colangite esclerosante &#233; de 48&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">O quadro cl&#237;nico de HAI &#233; altamente vari&#225;vel em crian&#231;as&#44; varia de hepatite aguda a in&#237;cio insidioso com fadiga progressiva&#44; icter&#237;cia intermitente&#44; anorexia e perda de peso&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a> O principal objetivo dos tratamentos imunossupressores &#233; melhorar as manifesta&#231;&#245;es cl&#237;nicas e os achados laboratoriais&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">1&#44;4</span></a> Um tratamento comum &#233; a prednisona&#44; que pode levar a efeitos colaterais como hipertricose&#44; ganho de peso e restri&#231;&#227;o do crescimento linear&#59; esses efeitos podem afetar a autoimagem e influenciar negativamente a sa&#250;de emocional&#44; comprometer&#44; assim&#44; a qualidade de vida relacionada &#224; sa&#250;de &#40;QVRS&#41; em crian&#231;as e adolescentes com HAI&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A doen&#231;a hep&#225;tica cr&#244;nica &#233; uma principal causa de &#243;bito em todo o mundo e &#233; respons&#225;vel por incapacitar um grande segmento da popula&#231;&#227;o economicamente ativa&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">5</span></a> Nesse contexto&#44; a QVRS dos pacientes com doen&#231;a hep&#225;tica cr&#244;nica desde a inf&#226;ncia ou adolesc&#234;ncia &#233; um importante determinante de sa&#250;de&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A expectativa de vida de pacientes pedi&#225;tricos com doen&#231;a hep&#225;tica cr&#244;nica melhorou significativamente na &#250;ltima d&#233;cada e a qualidade de vida relacionada &#224; sa&#250;de &#40;QVRS&#41; percebida pelo paciente assumiu um maior papel na determina&#231;&#227;o da qualidade da sobrevida aprimorada desses pacientes pedi&#225;tricos&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">6</span></a> Portanto&#44; foram desenvolvimentos instrumentos de medi&#231;&#227;o da QVRS de crian&#231;as&#44; adolescentes e seus pais&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Os instrumentos gerais de QVRS s&#227;o multidimensionais e t&#234;m o objetivo de avaliar o impacto de uma doen&#231;a em uma fun&#231;&#227;o da dor&#44; sa&#250;de geral&#44; vitalidade&#44; aspectos sociais e emocionais e sa&#250;de mental&#46; Os instrumentos s&#227;o bem projetados para avaliar a efic&#225;cia das pol&#237;ticas e programas de sa&#250;de ou comparar duas doen&#231;as distintas&#46; Instrumentos espec&#237;ficos focam nos sintomas&#44; defici&#234;ncias e limita&#231;&#245;es associados a uma doen&#231;a espec&#237;fica&#59; contudo&#44; n&#227;o h&#225; question&#225;rio espec&#237;fico para HAI na literatura&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Escolhemos a vers&#227;o gen&#233;rica do question&#225;rio PedsQL 4&#46;0 para este estudo devido &#224; sua facilidade de uso e suas avalia&#231;&#245;es globais&#44; inclusive aspectos f&#237;sicos&#44; emocionais&#44; sociais e escolares&#44; e ela tamb&#233;m possibilita a avalia&#231;&#227;o da percep&#231;&#227;o dos pais da QVRS de seu filho&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">A QVRS foi raramente estudada na popula&#231;&#227;o adulta e pedi&#225;trica com HAI com o uso de instrumentos gen&#233;ricos&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">9&#44;10</span></a> Aspectos emocionais negativos foram observados em pacientes adultos com HAI em compara&#231;&#227;o com a popula&#231;&#227;o geral&#44; independentemente do estado de remiss&#227;o da doen&#231;a&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a> No Brasil&#44; atualmente&#44; n&#227;o h&#225; estudos que abordem especificamente a QVRS de crian&#231;as e adolescentes com HAI&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">At&#233; onde sabemos&#44; h&#225; apenas um relato que avaliou a QVRS em pacientes com HAI com uma amostra de 22 crian&#231;as e adolescentes com HAI&#44; inclusive as submetidas a transplante de f&#237;gado&#44; que mostrou redu&#231;&#227;o na QVRS desses pacientes&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a> Contudo&#44; n&#227;o foi conclu&#237;da uma an&#225;lise dos dom&#237;nios de QVRS em pacientes pedi&#225;tricos sem transplante de f&#237;gado&#44; inclusive as compara&#231;&#245;es do estado de remiss&#227;o da doen&#231;a&#44; gravidade da doen&#231;a e dose de corticosteroide&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Os objetivos deste estudo foram avaliar a QVRS em pacientes com HAI e controles saud&#225;veis com o instrumento gen&#233;rico PedsQL 4&#46;0 para crian&#231;as&#47;adolescentes e seus respons&#225;veis legais e avaliar a poss&#237;vel influ&#234;ncia do estado de remiss&#227;o da doen&#231;a&#44; da gravidade da doen&#231;a e da dose de prednisona sobre a QVRS&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pacientes e m&#233;todos</span><p id="par0050" class="elsevierStylePara elsevierViewall">De mar&#231;o a dezembro de 2016&#44; foi feito um estudo transversal com 80 pacientes com HAI em duas unidades de hepatologia infantil de hospitais terci&#225;rios &#40;Instituto da Crian&#231;a da Faculdade de Medicina da Universidade de S&#227;o Paulo e Hospital Infantil Municipal Menino Jesus&#41; em S&#227;o Paulo&#44; Brasil&#46; Todos os pacientes foram avaliados sistematicamente e o diagn&#243;stico de HAI foi confirmado de acordo com os crit&#233;rios do Grupo Internacional de Hepatite Autoimune&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">11&#44;12</span></a> Este estudo foi aprovado pelos Comit&#234;s de &#201;tica dos hospitais&#46; Os pacientes&#44; controles e seus respons&#225;veis legais assinaram formul&#225;rios de consentimento informado&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Amostra</span><p id="par0055" class="elsevierStylePara elsevierViewall">Os pacientes foram selecionados com um m&#233;todo de amostragem de conveni&#234;ncia&#46; Os pacientes com HAI eram de diferentes regi&#245;es do Brasil&#44; e&#44; apesar de terem sido monitorados em duas unidades de hepatologia infantil localizadas em S&#227;o Paulo&#44; n&#227;o eram exclusivamente dessa cidade&#46; Os crit&#233;rios de inclus&#227;o foram os que seguem&#58; &#40;i&#41; entre cinco e 18 anos&#59; e &#40;ii&#41; diagn&#243;stico confirmado de hepatite autoimune&#46; Os crit&#233;rios de exclus&#227;o foram os que seguem&#58; &#40;i&#41; pacientes submetidos a transplante de f&#237;gado&#59; &#40;ii&#41; pacientes que se recusaram participar do estudo&#59; &#40;iii&#41; pacientes com hepatite fulminante&#59; e &#40;iv&#41; pacientes que n&#227;o receberam tratamento anterior&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Grupo de controle</span><p id="par0060" class="elsevierStylePara elsevierViewall">O grupo de controle consistiu em 45 crian&#231;as e adolescentes saud&#225;veis com perfil de idade semelhante dos pacientes &#91;13 &#40;5&#8208;18&#41; em compara&#231;&#227;o com 14 &#40;3&#8208;18&#41;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#44;804&#93; de uma escola p&#250;blica local em Cuiab&#225;&#44; Brasil&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Avalia&#231;&#245;es da QVRS</span><p id="par0065" class="elsevierStylePara elsevierViewall">A QVRS foi determinada com o Invent&#225;rio Pedi&#225;trico de Qualidade de Vida 4&#46;0 &#40;PedsQL 4&#46;0&#41;&#44; validado no idioma e na cultura portugueses &#40;Brasil&#41;&#46; Tr&#234;s vers&#245;es foram usadas com base na idade do paciente&#58; 5&#8208;7&#44; 8&#8208;12 ou 13&#8208;18 anos&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Dois instrumentos foram usados neste estudo&#58; o autorrelato das crian&#231;as PedsQL 4&#46;0 e o relato dos pais PedsQL 4&#46;0&#46; O question&#225;rio PedsQL 4&#46;0 inclui perguntas relacionadas aos seguintes quatro dom&#237;nios multidimensionais&#58; capacidade f&#237;sica&#44; aspectos emocionais&#44; aspectos sociais e atividades acad&#234;micas durante o m&#234;s anterior&#46; H&#225; 23 itens pontuados com uma escala de cinco pontos no grupo de 8&#8208;12 anos&#44; no grupo de 13&#8208;18 anos e nos grupos dos pais &#40;0 &#8211; nunca &#61; 100 pontos&#44; 1 &#8211; quase nunca &#61; 75 pontos&#44; 2 &#8211; &#224;s vezes &#61; 50 pontos&#44; 3 &#8211; frequentemente &#61; 25 pontos e 4 &#8211; quase sempre &#61; 0 pontos&#41; e uma escala de tr&#234;s pontos para o grupo 5&#8208;7 anos &#40;0 &#8211; nunca &#61; 100 pontos&#44; 2 &#8211; &#224;s vezes &#61; 50 pontos e 4 &#8211; frequentemente &#61; 0 pontos&#41;&#46; Os escores medianos variaram de 0 a 100 e um maior escore indica uma melhor QVRS&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">13&#44;14</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Avalia&#231;&#245;es demogr&#225;ficas&#44; cl&#237;nicas&#44; laboratoriais e terap&#234;uticas</span><p id="par0075" class="elsevierStylePara elsevierViewall">Os prontu&#225;rios m&#233;dicos dos pacientes foram revisados meticulosamente de acordo com um amplo protocolo padronizado para avaliar os dados demogr&#225;ficos&#44; as caracter&#237;sticas cl&#237;nicas&#44; os achados laboratoriais e os dados terap&#234;uticos&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Os dados demogr&#225;ficos inclu&#237;ram idade atual&#44; sexo e dura&#231;&#227;o da doen&#231;a &#40;tempo entre o diagn&#243;stico e a entrevista&#41;&#46; A HAI foi classificada como HAI tipo 1 &#91;presen&#231;a de anticorpos antinucleares &#40;ANA&#41; e&#47;ou anticorpo antim&#250;sculo liso &#40;SMA&#41;&#93; ou HAI tipo 2 &#91;presen&#231;a de anticorpo microssomal de f&#237;gado&#8208;rim anti&#8208;tipo I &#40;anti&#8208;LKM&#8208;1&#41; e&#47;ou anticorpo anticitosol hep&#225;tico &#40;anti&#8208;LC1&#41;&#93;&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">15&#44;16</span></a> A s&#237;ndrome da sobreposi&#231;&#227;o foi definida como HAI associada a colangite esclerosante autoimune com base em caracter&#237;sticas cl&#237;nicas&#47;bioqu&#237;micas da colestase e achados histol&#243;gicos ou colangiogr&#225;ficos&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a> Outras doen&#231;as autoimunes tamb&#233;m foram avaliadas&#44; inclusive <span class="elsevierStyleItalic">diabetes mellitus</span> tipo 1 &#8211; DMT1 &#40;com base em poli&#250;ria&#44; polidipsia&#44; perda de peso inexplicada e aumento na glicose plasm&#225;tica &#8805; 200<span class="elsevierStyleHsp" style=""></span>mg&#47;dL a qualquer momento do dia ou glicemia de jejum &#8805; 126<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a> e l&#250;pus eritematoso sist&#234;mico de in&#237;cio na inf&#226;ncia &#40;cSLE&#41;&#44; de acordo com os crit&#233;rios de classifica&#231;&#227;o do Col&#233;gio Americano de Reumatologia&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a> Os dados relacionados a prednisona&#44; azatioprina e outros medicamentos imunossupressores tamb&#233;m foram coletados&#44; bem como os achados laboratoriais no in&#237;cio do estudo&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Remiss&#227;o incompleta ou n&#227;o remiss&#227;o foi definida como n&#237;veis de aminotransferase duas vezes maiores do que o limite superior normal&#44; bem como alta concentra&#231;&#227;o de IgG ou globulina de soro&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Remiss&#227;o foi caracterizada como n&#237;veis de aminotransferases &#40;AST&#47;ALT&#41; e IgG abaixo do limite superior normal&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">A gravidade da doen&#231;a foi definida como hist&#243;rico anterior de complica&#231;&#245;es&#44; como hipertens&#227;o portal&#44; sangramento gastrointestinal superior&#44; ascite e&#47;ou peritonite bacteriana espont&#226;nea&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">21</span></a> Nenhum paciente apresentou essas complica&#231;&#245;es no momento da entrevista&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Dose de prednisona</span><p id="par0100" class="elsevierStylePara elsevierViewall">Os pacientes foram divididos de forma aleat&#243;ria nos dois seguintes grupos de acordo com a dose m&#233;dia de prednisona no momento da entrevista&#58; grupo A &#40;&#60; 0&#44;16<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;dia&#41; e grupo B &#40;&#8805; 0&#44;16<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;dia&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">An&#225;lises estat&#237;sticas</span><p id="par0105" class="elsevierStylePara elsevierViewall">Foram feitas com o programa estat&#237;stico SPSS &#40;IBM SPSS Estat&#237;stica para Windows&#44; vers&#227;o 22&#46;0&#46; NY&#44; EUA&#41;&#46; Os testes de Mann&#8208;Whitney ou <span class="elsevierStyleItalic">t</span> foram usados para comparar as vari&#225;veis cont&#237;nuas&#44; apresentadas como mediana &#40;intervalo&#41; ou m&#233;dia &#177; desvio&#8208;padr&#227;o &#40;DP&#41;&#44; respectivamente&#46; As diferen&#231;as nas frequ&#234;ncias das vari&#225;veis categ&#243;ricas foram avaliadas pelo teste exato de Fisher&#46; Os valores de <span class="elsevierStyleItalic">p</span> foram estabelecidos em 5&#37; &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#44;05&#41; para todos os testes estat&#237;sticos&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Resultados</span><p id="par0110" class="elsevierStylePara elsevierViewall">A <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a> inclui os dados demogr&#225;ficos&#44; os tipos de HAI&#44; outras doen&#231;as autoimunes&#44; medicamentos e achados laboratoriais em pacientes com HAI&#46; A m&#233;dia de idade atual foi semelhante para os pacientes com HAI e controles saud&#225;veis &#91;13 anos &#40;5&#8208;18&#41; em compara&#231;&#227;o com 14 anos &#40;3&#8208;18&#41;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#44;804&#41;&#46; HAI tipo 1 foi observada em 57 pacientes &#40;971&#37;&#41;&#44; colangite esclerosante autoimune em 11 &#40;14&#37;&#41;&#44; HAI Tipo 2 em 10 &#40;12&#37;&#41; e aus&#234;ncia de autoanticorpos em dois &#40;2&#37;&#41;&#46; A comorbidade DMT1 foi observada em tr&#234;s pacientes &#40;4&#37;&#41; e a comorbidade cSLE em um &#40;1&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Ao avaliar as caracter&#237;sticas cl&#237;nicas de todos os pacientes entrevistados&#44; a queixa mais comum foi dor abdominal&#44; relatada por 20 pacientes com HAI &#40;25&#37;&#41;&#46; Somente um paciente se queixou de hipertricose como efeito colateral do uso de prednisona e n&#227;o houve queixas de ganho de peso ou estrias&#46; Foram detectados hist&#243;rico de hipertens&#227;o portal em sete pacientes &#40;58&#44;4&#37;&#41;&#44; de sangramento gastrointestinal superior em dois &#40;16&#44;6&#37;&#41; e de ascite em tr&#234;s &#40;25&#37;&#41;&#46; Remiss&#227;o foi observada em 62 &#40;77&#44;5&#37;&#41; pacientes com HAI&#8208;1 e HAI&#8208;2 e remiss&#227;o incompleta ou n&#227;o remiss&#227;o em 18 com HAI&#8208;1 &#40;22&#44;5&#37;&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">A <a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a> ilustra os escores dos pacientes do PedsQL 4&#46;0 em compara&#231;&#227;o com controles saud&#225;veis e escores dos pais em compara&#231;&#227;o com os pais dos controles&#46; Os escores f&#237;sico&#44; emocional&#44; escolar e total foram significativamente menores em pacientes com HAI em compara&#231;&#227;o com os controles saud&#225;veis&#46; Os escores f&#237;sico e total foram significativamente menores em pais dos indiv&#237;duos com HAI em compara&#231;&#227;o com os pais dos controles&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">A <a class="elsevierStyleCrossRef" href="#tbl0015">tabela 3</a> mostra a m&#233;dia dos escores f&#237;sico&#44; social e total em pacientes com HAI que apresentaram dor abdominal em compara&#231;&#227;o com os que n&#227;o apresentaram dor abdominal&#46; Foi observado um preju&#237;zo significativo na QVRS nos escores f&#237;sico&#44; social&#44; escolar e total em pacientes com HAI com dor abdominal com base no relato dos pais&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">A an&#225;lise dos pacientes com HAI em remiss&#227;o incompleta ou n&#227;o remiss&#227;o em compara&#231;&#227;o com os pacientes em remiss&#227;o revelou m&#233;dia de escores f&#237;sico&#44; emocional&#44; social&#44; escolar ou total n&#227;o significativa nos autorrelatos dos pacientes com HAI ou nos relatos dos pais dos pacientes com HAI&#46; Uma an&#225;lise com base na gravidade da doen&#231;a n&#227;o mostrou diferen&#231;as significativas em qualquer dom&#237;nio nos relatos dos pacientes ou dos pais&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Uma an&#225;lise adicional dos pacientes com HAI com base na dose de prednisona&#44; em que o grupo A tomou uma dose de prednisona de &#60; 0&#44;16<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;dia e o grupo B uma dose de prednisona de &#8805; 0&#44;16<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;dia&#44; revelou que o escore f&#237;sico foi significativamente menor no grupo B&#46; Nenhuma diferen&#231;a foi vista nos escores f&#237;sico&#44; emocional&#44; social&#44; escolar ou total entre os grupos de uso de dose de prednisona com base nos relatos dos pais &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabela 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discuss&#227;o</span><p id="par0140" class="elsevierStylePara elsevierViewall">O presente estudo &#233; a primeira investiga&#231;&#227;o da QVRS em pacientes pedi&#225;tricos com HAI na Am&#233;rica do Sul&#46; Encontramos escores reduzidos em quase todos os dom&#237;nios &#40;f&#237;sico&#44; emocional&#44; escolar e total&#41; em pacientes com HAI em compara&#231;&#227;o com os controles&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">As doen&#231;as cr&#244;nicas s&#227;o conhecidas por colocar a QVRS em risco em todas as idades e apesar de as crian&#231;as de um a tr&#234;s anos geralmente n&#227;o conseguirem se expressar verbalmente&#44; elas conseguem comunicar seus problemas&#46; Esses sinais n&#227;o devem ser subestimados durante a consulta cl&#237;nica&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">22</span></a> No caso de adolescentes&#44; uma melhoria na QVRS &#233; essencial na promo&#231;&#227;o de ades&#227;o ao tratamento&#46; Apesar dessa import&#226;ncia&#44; estima&#8208;se que menos de 25&#37; dos pediatras usam as medi&#231;&#245;es de qualidade de vida em suas consultas&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a> H&#225; um interesse cada vez maior na adapta&#231;&#227;o e cria&#231;&#227;o de instru&#231;&#227;o para medir a QVRS em crian&#231;as e adolescentes devido a um aumento na preval&#234;ncia de doen&#231;as cr&#244;nicas nessa faixa et&#225;ria&#46; A maior parte desses instrumentos &#233; quantitativa e muitos deles s&#227;o espec&#237;ficos para algumas doen&#231;as&#46; Um grande desafio &#233; incorporar as medi&#231;&#245;es de QVRS na pr&#225;tica cl&#237;nica&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">7</span></a> A qualidade de vida &#233; um conceito relacionado a aspectos culturais&#59; assim&#44; os instrumentos de medi&#231;&#227;o da QVRS devem ser adaptados a culturas e idiomas locais&#46; N&#227;o h&#225; um question&#225;rio espec&#237;fico para crian&#231;as e adolescentes com hepatite autoimune &#40;HAI&#41; e pouco se sabe sobre a QVRS desses pacientes&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">As principais vantagens do presente estudo s&#227;o a avalia&#231;&#227;o sistem&#225;tica da QVRS em crian&#231;as e adolescentes com hepatite autoimune com uma amostra relativamente grande&#44; apesar dos poucos estudos anteriores&#44; e a exclus&#227;o de pacientes submetidos a transplante de f&#237;gado&#44; pois essa doen&#231;a pode reduzir a QVRS&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a> Al&#233;m disso&#44; um grupo de controle saud&#225;vel com perfil de idade semelhante foi inclu&#237;do no presente estudo&#46; A principal limita&#231;&#227;o deste estudo foi o uso de somente uma ferramenta gen&#233;rica para medir a QVRS em crian&#231;as com HAI e seus pais&#46; Um poss&#237;vel vi&#233;s foi a compara&#231;&#227;o exclusiva com um grupo de controle saud&#225;vel&#59; contudo&#44; n&#227;o h&#225; dados publicados sobre a QVRS de crian&#231;as e adolescentes com doen&#231;a hep&#225;tica cr&#244;nica no Brasil para outras compara&#231;&#245;es&#46; Como nossa amostra foi composta de crian&#231;as de diferentes regi&#245;es do Brasil&#44; podemos usar um grupo de controle de qualquer regi&#227;o com confian&#231;a&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">As queixas dos pais com rela&#231;&#227;o a manifesta&#231;&#245;es cl&#237;nicas foram muito mal relatadas&#44; com exce&#231;&#227;o de dor abdominal&#44; que chamou nossa aten&#231;&#227;o&#46; Nossos dados confirmam os relatos anteriores de que dor abdominal est&#225; associada a redu&#231;&#227;o na QVRS&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a> Esse achado pode estar relacionado aos efeitos colaterais de agentes imunossupressores&#44; complica&#231;&#245;es da HAI ou mesmo manifesta&#231;&#227;o psicossom&#225;ticas&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Observamos que a dose de corticosteroide est&#225; associada a redu&#231;&#227;o nos escores f&#237;sicos em crian&#231;as e adolescentes com HAI&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a> Mesmo baixas doses de corticosteroides n&#227;o devem ser subestimadas&#44; pois esses medicamentos podem afetar a composi&#231;&#227;o corporal e hipertricose&#44; acne&#44; estrias&#44; ganho de peso e altera&#231;&#245;es no crescimento e&#44; assim&#44; afetar os escores da QVRS&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">26</span></a> Apesar dessas manifesta&#231;&#245;es n&#227;o terem sido observadas em nossa amostra&#44; os escores f&#237;sicos dos pacientes com HAI mostraram redu&#231;&#227;o&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Aproximadamente um quinto de nossos pacientes com HAI estava em remiss&#227;o incompleta no momento da entrevista&#44; apesar de essa vari&#225;vel n&#227;o influenciar a QVRS&#46; Esse achado tamb&#233;m foi observado na popula&#231;&#227;o adulta com HAI&#46; Portanto&#44; a QVRS poder&#225; ser reduzida em pacientes em remiss&#227;o&#44; bem como em pacientes que iniciam tratamento&#46; Esses achados corroboram a vis&#227;o de que a QVRS &#233; uma medida individual e subjetiva que deve ser considerada no tratamento individualizado de cada paciente&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">9&#44;22</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Um hist&#243;rico pr&#233;vio de complica&#231;&#245;es n&#227;o influenciou a QVRS de crian&#231;as ou adolescentes com HAI&#46; Os relatos dos pais revelaram escores de QVRS mais baixos somente no dom&#237;nio f&#237;sico&#44; um achado que difere de um relato anterior que sugere que todos os dom&#237;nios&#44; exceto o social&#44; foram prejudicados&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a> Adicionalmente&#44; a avalia&#231;&#227;o da QVRS pelos pais difere de pacientes em que quase todos os dom&#237;nios apresentam redu&#231;&#227;o&#46; Talvez os pais tenham confundido os sintomas emocionais dos filhos com sintomas f&#237;sicos e tenham interpretado de forma err&#244;nea tristeza como dor f&#237;sica&#46; Existe a possibilidade de que as diferen&#231;as culturais e socioecon&#244;micas entre nossa amostra de pais e a amostra no estudo anterior tenham levado a essa discrep&#226;ncia nos achados&#44; apesar de o instrumento ser validado para situa&#231;&#227;o cultural e socioecon&#244;mica&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">As doen&#231;as cr&#244;nicas na popula&#231;&#227;o pedi&#225;trica reduzem a QVRS&#44; principalmente doen&#231;as com dor f&#237;sica grave ou aquelas que exigem tratamentos mais agressivos&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a> Apesar de a HAI n&#227;o mostrar essas caracter&#237;sticas e geralmente responder bem a tratamento&#44; nossos resultados mostram uma redu&#231;&#227;o significativa na QVRS em todos os dom&#237;nios&#44; exceto social&#44; para pacientes com HAI em compara&#231;&#227;o com controles saud&#225;veis&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">10&#44;28</span></a> Para pacientes com HAI&#44; o tratamento de quaisquer sintomas f&#237;sicos que podem ocorrer n&#227;o elimina a doen&#231;a cr&#244;nica na inf&#226;ncia e adolesc&#234;ncia e o al&#237;vio dos sintomas f&#237;sicos n&#227;o necessariamente indica melhor QVRS&#46; Apesar de todos os dom&#237;nios testados estarem relacionados entre si&#44; ou seja&#44; caso o preju&#237;zo emocional afete o dom&#237;nio f&#237;sico&#44; os dom&#237;nios f&#237;sico e escolar devem ser mais investigados&#44; pois a HAI n&#227;o causa sintomas f&#237;sicos ou redu&#231;&#227;o cognitiva significativos&#46; Existe a possibilidade de faltas escolares causadas por consultas regulares de acompanhamento&#44; necess&#225;rias para exames m&#233;dicos&#44; poderem prejudicar o desempenho escolar&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Notavelmente&#44; uma pesquisa anterior indica que as crian&#231;as conseguem demonstrar seus pr&#243;prios sentimentos e queixas com uma avalia&#231;&#227;o confi&#225;vel de sua pr&#243;pria QVRS&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a> Assim&#44; instrumentos espec&#237;ficos para medir a QVRS em v&#225;rias doen&#231;as em crian&#231;as e adolescentes t&#234;m sido desenvolvidos e ser&#227;o necess&#225;rios estudos adicionais que avaliem novas ferramentas espec&#237;ficas para avaliar a QVRS em pacientes com HAI&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Escores reduzidos nos dom&#237;nios f&#237;sico&#44; emocional e escolar foram observados em pacientes pedi&#225;tricos com HAI&#46; Dor abdominal e dose de corticosteroide influenciaram negativamente a QVRS em crian&#231;as e adolescentes com HAI&#46; A gravidade da doen&#231;a e o estado de remiss&#227;o da doen&#231;a n&#227;o influenciaram a QVRS na popula&#231;&#227;o pedi&#225;trica com HAI&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Por fim&#44; nossos resultados destacam a urg&#234;ncia de dar aten&#231;&#227;o a sintomas f&#237;sicos&#44; escolares e emocionais de pacientes com HAI e ao desenvolvimento de um instrumento espec&#237;fico de medi&#231;&#227;o da QVRS para crian&#231;as e adolescentes com HAI&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflitos de interesse</span><p id="par0195" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflitos de interesse&#46;</p></span></span>"
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          "titulo" => "Pacientes e m&#233;todos"
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              "titulo" => "Avalia&#231;&#245;es demogr&#225;ficas&#44; cl&#237;nicas&#44; laboratoriais e terap&#234;uticas"
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              "identificador" => "sec0035"
              "titulo" => "Dose de prednisona"
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    "fechaRecibido" => "2017-07-26"
    "fechaAceptado" => "2017-10-30"
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            0 => "Quality of life"
            1 => "Autoimmune hepatitis"
            2 => "Childhood"
            3 => "Adolescence"
            4 => "Chronic disease"
            5 => "PedsQL 4&#46;0"
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            0 => "Qualidade de vida"
            1 => "Hepatite autoimune"
            2 => "Inf&#226;ncia"
            3 => "Adolesc&#234;ncia"
            4 => "Doen&#231;a cr&#244;nica"
            5 => "PedsQL 4&#46;0"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The objective of this study was to evaluate the health&#8208;related quality of life in children and adolescents with autoimmune hepatitis&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A cross&#8208;sectional assessment with the Pediatric Quality of Life Inventory 4&#46;0 &#40;PedsQL 4&#46;0&#41; was completed for 80 patients with autoimmune hepatitis and 45 healthy controls&#46; Demographic data&#44; prednisone dose&#44; disease remission state&#44; disease severity&#44; and abdominal pain were also evaluated&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Based on the child self&#8208;reports&#44; physical&#44; emotional&#44; school&#44; and total scores were significantly lower in autoimmune hepatitis patients when compared with controls &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Based on the parental reports&#44; only the physical and total scores were significantly lower in autoimmune hepatitis patients <span class="elsevierStyleItalic">versus</span> controls &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Further analysis in autoimmune hepatitis patients with abdominal pain in the last month revealed significantly lower physical&#44; social&#44; and total median scores &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; No differences were observed based on disease remission state or disease severity &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Autoimmune hepatitis patients who received a prednisone dose below 0&#46;16<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day at the time of the interview showed significantly higher physical scores than those who received a dose similar to or above 0&#46;16<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day &#40;87&#46;5 &#91;50&#8211;100&#93; <span class="elsevierStyleItalic">vs</span>&#46; 75 &#91;15&#46;63&#8211;100&#93;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;006&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Reduced scores in the physical&#44; emotional&#44; and school domains were observed in pediatric autoimmune hepatitis patients compared to control patients&#46; Abdominal pain and corticosteroid dose negatively influenced the health&#8208;related quality of life in children and adolescents with autoimmune hepatitis&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Avaliar a qualidade de vida relacionada &#224; sa&#250;de em crian&#231;as e adolescentes com hepatite autoimune &#40;HAI&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Foi conclu&#237;da uma avalia&#231;&#227;o transversal com o Invent&#225;rio Pedi&#225;trico de Qualidade de Vida 4&#46;0 &#40;PedsQL 4&#46;0&#41; para 80 pacientes com hepatite autoimune e 45 controles saud&#225;veis&#46; Os dados demogr&#225;ficos&#44; a dose de prednisona&#44; o estado de remiss&#227;o da doen&#231;a&#44; a gravidade da doen&#231;a e dor abdominal tamb&#233;m foram avaliados&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Com base nos autorrelatos das crian&#231;as&#44; os escores f&#237;sico&#44; emocional&#44; escolar e total foram significativamente menores em pacientes com hepatite autoimune em compara&#231;&#227;o com os controles &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#44;05&#41;&#46; Com base nos relatos dos pais&#44; apenas os escores f&#237;sico e total foram significativamente menores em pacientes com hepatite autoimune em compara&#231;&#227;o com os controles &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#44;05&#41;&#46; Uma an&#225;lise adicional em pacientes com hepatite autoimune com dor abdominal no m&#234;s passado revelou escores m&#233;dios f&#237;sico&#44; social e total significativamente menores &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#44;05&#41;&#46; Nenhuma diferen&#231;a foi observada com base no estado de remiss&#227;o da doen&#231;a ou na gravidade da doen&#231;a &#40;<span class="elsevierStyleItalic">p</span> &#62; 0&#44;05&#41;&#46; Os pacientes com hepatite autoimune que receberam uma dose de prednisona abaixo de 0&#44;16<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;dia no momento da entrevista mostraram escores f&#237;sicos significativamente maiores que os que receberam uma dose semelhante ou acima de 0&#44;16<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;dia &#91;87&#44;5 &#40;50&#8208;100&#41; em compara&#231;&#227;o com 75 &#40;15&#44;63&#8208;100&#41;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#44;006&#93;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Escores reduzidos nos dom&#237;nios f&#237;sico&#44; emocional e escolar foram observados em pacientes pedi&#225;tricos com hepatite autoimune em compara&#231;&#227;o com pacientes do grupo de controle&#46; Dor abdominal e dose de corticosteroide influenciaram negativamente a qualidade de vida relacionada &#224; sa&#250;de em crian&#231;as e adolescentes com hepatite autoimune&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Como citar este artigo&#58; Bozzini AB&#44; Neder L&#44; Silva CA&#44; Porta G&#46; Decreased health&#8208;related quality of life in children and adolescents with autoimmune hepatitis&#46; J Pediatr &#40;Rio J&#41;&#46; 2019&#59;95&#58;87&#8211;93&#46;</p>"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Os resultados s&#227;o apresentados em mediana &#40;intervalo&#41; e n &#40;&#37;&#41;&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Vari&#225;veis no in&#237;cio do estudo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pacientes com HAI &#40;n &#61; 80&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Dados demogr&#225;ficos</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Idade atual&#44; anos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13 &#40;5&#8208;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sexo feminino&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56 &#40;70&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Dura&#231;&#227;o da doen&#231;a&#44; anos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#44;9 &#40;3&#44;06&#8208;4&#44;75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Tipo de hepatite autoimune</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>HAI&#8208;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57 &#40;71&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>HAI e colangite esclerosante autoimune &#40;s&#237;ndrome da sobreposi&#231;&#227;o&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11 &#40;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>HAI&#8208;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Aus&#234;ncia de autoanticorpos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Outra doen&#231;a autoimune</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Diabetes mellitus tipo 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>L&#250;pus eritematoso sist&#234;mico de in&#237;cio na inf&#226;ncia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Medicamentos</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Somente prednisona&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Prednisona e azatioprina&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sem tratamento&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Achados laboratoriais</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>AST&#44;U&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">36&#40;13&#8208;5205&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ALT&#44;U&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">36&#44;5&#40;8&#8208;1119&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>GGT&#44;U&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">41&#44;5&#40;10&#8208;941&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ALP&#44;U&#47;l&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">159&#40;9&#8208;473&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>INR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;16&#40;0&#44;96&#8208;2&#44;03&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bilirrubina&#44; mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;71&#40;0&#44;21&#8208;13&#44;65&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Albumina&#44; g&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#40;2&#44;93&#8208;15&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "pt" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Dados demogr&#225;ficos&#44; tipos de hepatite autoimune &#40;HAI&#41;&#44; outras doen&#231;as autoimunes&#44; medicamentos e achados laboratoriais para pacientes com HAI no in&#237;cio do estudo</p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Os resultados s&#227;o apresentados em mediana &#40;intervalo&#41; pelo teste de Mann&#8208;Whitney&#46;</p>"
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pacientes com HAI<br>&#40;n &#61; 80&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Social&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90 &#40;45&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;427&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90 &#40;40&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Escore total&nbsp;\t\t\t\t\t\t\n
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            1 => array:2 [
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                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pais de crian&#231;as com HAI<br>&#40;n &#61; 58&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75 &#40;25&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Escolar&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;246&nbsp;\t\t\t\t\t\t\n
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          "pt" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Escores do Invent&#225;rio Pedi&#225;trico de Qualidade de Vida 4&#46;0 &#40;PedsQL 4&#46;0&#41; de acordo com os relatos de pacientes com hepatite autoimune &#40;HAI&#41; e controles saud&#225;veis e seus pais</p>"
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Os resultados s&#227;o apresentados em mediana &#40;intervalo&#41; pelo teste de Mann&#8208;Whitney&#46;</p>"
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                0 => """
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&#44;18 &#40;15&#44;63&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Emocional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65 &#40;20&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&#44;50 &#40;5&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Escolar&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;262&nbsp;\t\t\t\t\t\t\n
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            1 => array:2 [
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>F&#237;sico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87&#44;50 &#40;43&#44;75&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75 &#40;3&#44;13&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Emocional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65 &#40;25&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70 &#40;5&#8208;95&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;910&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Social&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100 &#40;20&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95 &#40;10&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;027&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Escolar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">85 &#40;55&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&#44;50&#40;20&#8208;95&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;012&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">81&#44;79 &#40;57&#44;97&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;016&nbsp;\t\t\t\t\t\t\n
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          "pt" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Escores do Invent&#225;rio Pedi&#225;trico de Qualidade de Vida 4&#46;0 &#40;PedsQL 4&#46;0&#41; de crian&#231;as e adolescentes com hepatite autoimune &#40;HAI&#41; e seus pais&#44; de acordo com a presen&#231;a de dor abdominal</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pais de crian&#231;as com HAI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63&#44;22 &#40;54&#44;86&#8208;71&#44;58&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">89&#44;83 &#40;81&#44;79&#8208;97&#44;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;965&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">79&#44;13 &#40;71&#44;70&#8208;86&#44;55&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;578&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">81&#44;27 &#40;76&#44;66&#8208;85&#44;89&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;290&nbsp;\t\t\t\t\t\t\n
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          "pt" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Escores do Invent&#225;rio Pedi&#225;trico de Qualidade de Vida 4&#46;0 &#40;PedsQL 4&#46;0&#41; de crian&#231;as e adolescentes de acordo com a mediana da dose de prednisona no momento da entrevista&#58; Grupo A &#40;&#60; 0&#44;16<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;dia&#41; em compara&#231;&#227;o com o Grupo B &#40;&#8805; 0&#44;16<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;dia&#41;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "Refer&#234;ncias"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:29 [
            0 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The management of childhood liver diseases in adulthood"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "D&#46; Joshi"
                            1 => "N&#46; Gupta"
                            2 => "M&#46; Samyn"
                            3 => "M&#46; Deheragoda"
                            4 => "F&#46; Dobbels"
                            5 => "M&#46;A&#46; Heneghan"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jhep.2016.11.013"
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                        "tituloSerie" => "J Hepatol"
                        "fecha" => "2017"
                        "volumen" => "66"
                        "paginaInicial" => "631"
                        "paginaFinal" => "644"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27914924"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
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            1 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sclerosing cholangitis in children and adolescents"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "G&#46;M&#46; Vergani"
                            1 => "D&#46; Vergani"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.cld.2015.08.008"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Liver Dis"
                        "fecha" => "2016"
                        "volumen" => "20"
                        "paginaInicial" => "99"
                        "paginaFinal" => "111"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26593293"
                            "web" => "Medline"
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                      ]
                    ]
                  ]
                ]
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            2 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Autoimmune hepatitis in children&#58; what is different from adult AIH&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "D&#46; Vergani"
                            1 => "G&#46;M&#46; Vergani"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1055/s-0029-1233529"
                      "Revista" => array:6 [
                        "tituloSerie" => "Semin Liver Dis"
                        "fecha" => "2009"
                        "volumen" => "29"
                        "paginaInicial" => "297"
                        "paginaFinal" => "300"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19676002"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pediatric liver diseases&#58; current challenges and future perspectives"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "C&#46;D&#46; Corte"
                            1 => "A&#46; Mosca"
                            2 => "A&#46; Vania"
                            3 => "A&#46; Alterio"
                            4 => "A&#46; Alisi"
                            5 => "V&#46; Nobili"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1586/17474124.2016.1129274"
                      "Revista" => array:6 [
                        "tituloSerie" => "Expert Rev Gastroenterol Hepatol"
                        "fecha" => "2016"
                        "volumen" => "10"
                        "paginaInicial" => "255"
                        "paginaFinal" => "265"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26641319"
                            "web" => "Medline"
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            4 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The epidemiology of newly diagnosed chronic liver disease in gastroenterology practices in the United States&#58; results from population&#8208;based surveillance"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "B&#46;P&#46; Bell"
                            1 => "M&#46;M&#46; Manos"
                            2 => "A&#46; Zaman"
                            3 => "N&#46; Terrault"
                            4 => "A&#46; Thomas"
                            5 => "V&#46;J&#46; Navarro"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1572-0241.2008.02071.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Gastroenterol"
                        "fecha" => "2008"
                        "volumen" => "103"
                        "paginaInicial" => "2727"
                        "paginaFinal" => "2736"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18684170"
                            "web" => "Medline"
                          ]
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                      ]
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            5 => array:3 [
              "identificador" => "bib0175"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "PedsQL&#8482; Cognitive Functioning Scale in pediatric liver transplant recipients&#58; feasibility&#44; reliability&#44; and validity"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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Artigo Original
Decreased health‐related quality of life in children and adolescents with autoimmune hepatitis
Redução na qualidade de vida relacionada à saúde em crianças e adolescentes com hepatite autoimune
Ana Beatriz Bozzinia,
Autor para correspondência
anabeatrizbozzini@gmail.com

Autor para correspondência.
, Luciana Nederb, Clovis A. Silvaa, Gilda Portac
a Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Pediatria, São Paulo, SP, Brasil
b Universidade Federal do Mato Grosso (UFMT), Departamento de Clínicas, Cuiabá, MT, Brasil
c Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Programa de Pós-graduação Pediátrica, São Paulo, SP, Brasil
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&#40;momento 1&#41; 11 &#40;FC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>masculino&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>34&#44;5&#44; 12 &#40;FC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>feminino&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>34&#44;1&#44; 21 &#40;controles<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>masculino&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>17&#44;25&#44; 22 &#40;controles<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>feminino&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#44;29&#44; &#40;momento 2&#41; 11<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>24&#44;96&#44; 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21<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>13&#44;72&#44; 22<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#44;76&#44; &#40;momento 5&#41; 11<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>37&#44;12&#44; 12<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>32&#44;31&#44; 21<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>14&#44;87&#44; 22<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#44;37&#46; <span class="elsevierStyleBold">B&#46;</span> Associa&#231;&#227;o do volume do Slope 3&#47;corrente entre indiv&#237;duos com FC &#40;1&#41; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>64&#41; e controles saud&#225;veis &#40;controles&#44; 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&#40;momento 4&#41; 1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#44; 2<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#44; &#40;momento 5&#41; 1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;1&#44; 2<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#46; <span class="elsevierStyleBold">2&#46;</span> Associa&#231;&#227;o do slope 3 com FC e controles considerando a idade&#46; &#40;momento 1&#41; 11 &#40;FC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>12 anos&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;14&#44; 12 &#40;FC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>&#8805; 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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introdu&#231;&#227;o</span><p id="par0005" class="elsevierStylePara elsevierViewall">Hepatite autoimune &#40;HAI&#41; &#233; uma doen&#231;a hep&#225;tica inflamat&#243;ria cr&#244;nica e progressiva&#46; A HAI &#233; imunomediada&#44; caracterizada por altos n&#237;veis s&#233;ricos de aminotransferases e imunoglobulina G &#40;IgG&#41; e detect&#225;vel por autoanticorpos e comprova&#231;&#227;o histol&#243;gica de hepatite interface na aus&#234;ncia de uma etiologia conhecida&#46; A HAI &#233; uma condi&#231;&#227;o rara com incid&#234;ncia relatada de 0&#44;4 a 3 por 100&#46;000 crian&#231;as&#46; A HAI pode ocorrer juntamente com outras doen&#231;as autoimunes&#44; como diabetes Tipo I&#44; hipotireoidismo e l&#250;pus eritematoso sist&#234;mico&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">1&#44;2</span></a> A preval&#234;ncia da HAI&#47;s&#237;ndrome da sobreposi&#231;&#227;o com colangite esclerosante &#233; de 48&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">O quadro cl&#237;nico de HAI &#233; altamente vari&#225;vel em crian&#231;as&#44; varia de hepatite aguda a in&#237;cio insidioso com fadiga progressiva&#44; icter&#237;cia intermitente&#44; anorexia e perda de peso&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a> O principal objetivo dos tratamentos imunossupressores &#233; melhorar as manifesta&#231;&#245;es cl&#237;nicas e os achados laboratoriais&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">1&#44;4</span></a> Um tratamento comum &#233; a prednisona&#44; que pode levar a efeitos colaterais como hipertricose&#44; ganho de peso e restri&#231;&#227;o do crescimento linear&#59; esses efeitos podem afetar a autoimagem e influenciar negativamente a sa&#250;de emocional&#44; comprometer&#44; assim&#44; a qualidade de vida relacionada &#224; sa&#250;de &#40;QVRS&#41; em crian&#231;as e adolescentes com HAI&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A doen&#231;a hep&#225;tica cr&#244;nica &#233; uma principal causa de &#243;bito em todo o mundo e &#233; respons&#225;vel por incapacitar um grande segmento da popula&#231;&#227;o economicamente ativa&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">5</span></a> Nesse contexto&#44; a QVRS dos pacientes com doen&#231;a hep&#225;tica cr&#244;nica desde a inf&#226;ncia ou adolesc&#234;ncia &#233; um importante determinante de sa&#250;de&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A expectativa de vida de pacientes pedi&#225;tricos com doen&#231;a hep&#225;tica cr&#244;nica melhorou significativamente na &#250;ltima d&#233;cada e a qualidade de vida relacionada &#224; sa&#250;de &#40;QVRS&#41; percebida pelo paciente assumiu um maior papel na determina&#231;&#227;o da qualidade da sobrevida aprimorada desses pacientes pedi&#225;tricos&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">6</span></a> Portanto&#44; foram desenvolvimentos instrumentos de medi&#231;&#227;o da QVRS de crian&#231;as&#44; adolescentes e seus pais&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Os instrumentos gerais de QVRS s&#227;o multidimensionais e t&#234;m o objetivo de avaliar o impacto de uma doen&#231;a em uma fun&#231;&#227;o da dor&#44; sa&#250;de geral&#44; vitalidade&#44; aspectos sociais e emocionais e sa&#250;de mental&#46; Os instrumentos s&#227;o bem projetados para avaliar a efic&#225;cia das pol&#237;ticas e programas de sa&#250;de ou comparar duas doen&#231;as distintas&#46; Instrumentos espec&#237;ficos focam nos sintomas&#44; defici&#234;ncias e limita&#231;&#245;es associados a uma doen&#231;a espec&#237;fica&#59; contudo&#44; n&#227;o h&#225; question&#225;rio espec&#237;fico para HAI na literatura&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Escolhemos a vers&#227;o gen&#233;rica do question&#225;rio PedsQL 4&#46;0 para este estudo devido &#224; sua facilidade de uso e suas avalia&#231;&#245;es globais&#44; inclusive aspectos f&#237;sicos&#44; emocionais&#44; sociais e escolares&#44; e ela tamb&#233;m possibilita a avalia&#231;&#227;o da percep&#231;&#227;o dos pais da QVRS de seu filho&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">A QVRS foi raramente estudada na popula&#231;&#227;o adulta e pedi&#225;trica com HAI com o uso de instrumentos gen&#233;ricos&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">9&#44;10</span></a> Aspectos emocionais negativos foram observados em pacientes adultos com HAI em compara&#231;&#227;o com a popula&#231;&#227;o geral&#44; independentemente do estado de remiss&#227;o da doen&#231;a&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a> No Brasil&#44; atualmente&#44; n&#227;o h&#225; estudos que abordem especificamente a QVRS de crian&#231;as e adolescentes com HAI&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">At&#233; onde sabemos&#44; h&#225; apenas um relato que avaliou a QVRS em pacientes com HAI com uma amostra de 22 crian&#231;as e adolescentes com HAI&#44; inclusive as submetidas a transplante de f&#237;gado&#44; que mostrou redu&#231;&#227;o na QVRS desses pacientes&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a> Contudo&#44; n&#227;o foi conclu&#237;da uma an&#225;lise dos dom&#237;nios de QVRS em pacientes pedi&#225;tricos sem transplante de f&#237;gado&#44; inclusive as compara&#231;&#245;es do estado de remiss&#227;o da doen&#231;a&#44; gravidade da doen&#231;a e dose de corticosteroide&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Os objetivos deste estudo foram avaliar a QVRS em pacientes com HAI e controles saud&#225;veis com o instrumento gen&#233;rico PedsQL 4&#46;0 para crian&#231;as&#47;adolescentes e seus respons&#225;veis legais e avaliar a poss&#237;vel influ&#234;ncia do estado de remiss&#227;o da doen&#231;a&#44; da gravidade da doen&#231;a e da dose de prednisona sobre a QVRS&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pacientes e m&#233;todos</span><p id="par0050" class="elsevierStylePara elsevierViewall">De mar&#231;o a dezembro de 2016&#44; foi feito um estudo transversal com 80 pacientes com HAI em duas unidades de hepatologia infantil de hospitais terci&#225;rios &#40;Instituto da Crian&#231;a da Faculdade de Medicina da Universidade de S&#227;o Paulo e Hospital Infantil Municipal Menino Jesus&#41; em S&#227;o Paulo&#44; Brasil&#46; Todos os pacientes foram avaliados sistematicamente e o diagn&#243;stico de HAI foi confirmado de acordo com os crit&#233;rios do Grupo Internacional de Hepatite Autoimune&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">11&#44;12</span></a> Este estudo foi aprovado pelos Comit&#234;s de &#201;tica dos hospitais&#46; Os pacientes&#44; controles e seus respons&#225;veis legais assinaram formul&#225;rios de consentimento informado&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Amostra</span><p id="par0055" class="elsevierStylePara elsevierViewall">Os pacientes foram selecionados com um m&#233;todo de amostragem de conveni&#234;ncia&#46; Os pacientes com HAI eram de diferentes regi&#245;es do Brasil&#44; e&#44; apesar de terem sido monitorados em duas unidades de hepatologia infantil localizadas em S&#227;o Paulo&#44; n&#227;o eram exclusivamente dessa cidade&#46; Os crit&#233;rios de inclus&#227;o foram os que seguem&#58; &#40;i&#41; entre cinco e 18 anos&#59; e &#40;ii&#41; diagn&#243;stico confirmado de hepatite autoimune&#46; Os crit&#233;rios de exclus&#227;o foram os que seguem&#58; &#40;i&#41; pacientes submetidos a transplante de f&#237;gado&#59; &#40;ii&#41; pacientes que se recusaram participar do estudo&#59; &#40;iii&#41; pacientes com hepatite fulminante&#59; e &#40;iv&#41; pacientes que n&#227;o receberam tratamento anterior&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Grupo de controle</span><p id="par0060" class="elsevierStylePara elsevierViewall">O grupo de controle consistiu em 45 crian&#231;as e adolescentes saud&#225;veis com perfil de idade semelhante dos pacientes &#91;13 &#40;5&#8208;18&#41; em compara&#231;&#227;o com 14 &#40;3&#8208;18&#41;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#44;804&#93; de uma escola p&#250;blica local em Cuiab&#225;&#44; Brasil&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Avalia&#231;&#245;es da QVRS</span><p id="par0065" class="elsevierStylePara elsevierViewall">A QVRS foi determinada com o Invent&#225;rio Pedi&#225;trico de Qualidade de Vida 4&#46;0 &#40;PedsQL 4&#46;0&#41;&#44; validado no idioma e na cultura portugueses &#40;Brasil&#41;&#46; Tr&#234;s vers&#245;es foram usadas com base na idade do paciente&#58; 5&#8208;7&#44; 8&#8208;12 ou 13&#8208;18 anos&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Dois instrumentos foram usados neste estudo&#58; o autorrelato das crian&#231;as PedsQL 4&#46;0 e o relato dos pais PedsQL 4&#46;0&#46; O question&#225;rio PedsQL 4&#46;0 inclui perguntas relacionadas aos seguintes quatro dom&#237;nios multidimensionais&#58; capacidade f&#237;sica&#44; aspectos emocionais&#44; aspectos sociais e atividades acad&#234;micas durante o m&#234;s anterior&#46; H&#225; 23 itens pontuados com uma escala de cinco pontos no grupo de 8&#8208;12 anos&#44; no grupo de 13&#8208;18 anos e nos grupos dos pais &#40;0 &#8211; nunca &#61; 100 pontos&#44; 1 &#8211; quase nunca &#61; 75 pontos&#44; 2 &#8211; &#224;s vezes &#61; 50 pontos&#44; 3 &#8211; frequentemente &#61; 25 pontos e 4 &#8211; quase sempre &#61; 0 pontos&#41; e uma escala de tr&#234;s pontos para o grupo 5&#8208;7 anos &#40;0 &#8211; nunca &#61; 100 pontos&#44; 2 &#8211; &#224;s vezes &#61; 50 pontos e 4 &#8211; frequentemente &#61; 0 pontos&#41;&#46; Os escores medianos variaram de 0 a 100 e um maior escore indica uma melhor QVRS&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">13&#44;14</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Avalia&#231;&#245;es demogr&#225;ficas&#44; cl&#237;nicas&#44; laboratoriais e terap&#234;uticas</span><p id="par0075" class="elsevierStylePara elsevierViewall">Os prontu&#225;rios m&#233;dicos dos pacientes foram revisados meticulosamente de acordo com um amplo protocolo padronizado para avaliar os dados demogr&#225;ficos&#44; as caracter&#237;sticas cl&#237;nicas&#44; os achados laboratoriais e os dados terap&#234;uticos&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Os dados demogr&#225;ficos inclu&#237;ram idade atual&#44; sexo e dura&#231;&#227;o da doen&#231;a &#40;tempo entre o diagn&#243;stico e a entrevista&#41;&#46; A HAI foi classificada como HAI tipo 1 &#91;presen&#231;a de anticorpos antinucleares &#40;ANA&#41; e&#47;ou anticorpo antim&#250;sculo liso &#40;SMA&#41;&#93; ou HAI tipo 2 &#91;presen&#231;a de anticorpo microssomal de f&#237;gado&#8208;rim anti&#8208;tipo I &#40;anti&#8208;LKM&#8208;1&#41; e&#47;ou anticorpo anticitosol hep&#225;tico &#40;anti&#8208;LC1&#41;&#93;&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">15&#44;16</span></a> A s&#237;ndrome da sobreposi&#231;&#227;o foi definida como HAI associada a colangite esclerosante autoimune com base em caracter&#237;sticas cl&#237;nicas&#47;bioqu&#237;micas da colestase e achados histol&#243;gicos ou colangiogr&#225;ficos&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a> Outras doen&#231;as autoimunes tamb&#233;m foram avaliadas&#44; inclusive <span class="elsevierStyleItalic">diabetes mellitus</span> tipo 1 &#8211; DMT1 &#40;com base em poli&#250;ria&#44; polidipsia&#44; perda de peso inexplicada e aumento na glicose plasm&#225;tica &#8805; 200<span class="elsevierStyleHsp" style=""></span>mg&#47;dL a qualquer momento do dia ou glicemia de jejum &#8805; 126<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a> e l&#250;pus eritematoso sist&#234;mico de in&#237;cio na inf&#226;ncia &#40;cSLE&#41;&#44; de acordo com os crit&#233;rios de classifica&#231;&#227;o do Col&#233;gio Americano de Reumatologia&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a> Os dados relacionados a prednisona&#44; azatioprina e outros medicamentos imunossupressores tamb&#233;m foram coletados&#44; bem como os achados laboratoriais no in&#237;cio do estudo&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Remiss&#227;o incompleta ou n&#227;o remiss&#227;o foi definida como n&#237;veis de aminotransferase duas vezes maiores do que o limite superior normal&#44; bem como alta concentra&#231;&#227;o de IgG ou globulina de soro&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Remiss&#227;o foi caracterizada como n&#237;veis de aminotransferases &#40;AST&#47;ALT&#41; e IgG abaixo do limite superior normal&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">A gravidade da doen&#231;a foi definida como hist&#243;rico anterior de complica&#231;&#245;es&#44; como hipertens&#227;o portal&#44; sangramento gastrointestinal superior&#44; ascite e&#47;ou peritonite bacteriana espont&#226;nea&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">21</span></a> Nenhum paciente apresentou essas complica&#231;&#245;es no momento da entrevista&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Dose de prednisona</span><p id="par0100" class="elsevierStylePara elsevierViewall">Os pacientes foram divididos de forma aleat&#243;ria nos dois seguintes grupos de acordo com a dose m&#233;dia de prednisona no momento da entrevista&#58; grupo A &#40;&#60; 0&#44;16<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;dia&#41; e grupo B &#40;&#8805; 0&#44;16<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;dia&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">An&#225;lises estat&#237;sticas</span><p id="par0105" class="elsevierStylePara elsevierViewall">Foram feitas com o programa estat&#237;stico SPSS &#40;IBM SPSS Estat&#237;stica para Windows&#44; vers&#227;o 22&#46;0&#46; NY&#44; EUA&#41;&#46; Os testes de Mann&#8208;Whitney ou <span class="elsevierStyleItalic">t</span> foram usados para comparar as vari&#225;veis cont&#237;nuas&#44; apresentadas como mediana &#40;intervalo&#41; ou m&#233;dia &#177; desvio&#8208;padr&#227;o &#40;DP&#41;&#44; respectivamente&#46; As diferen&#231;as nas frequ&#234;ncias das vari&#225;veis categ&#243;ricas foram avaliadas pelo teste exato de Fisher&#46; Os valores de <span class="elsevierStyleItalic">p</span> foram estabelecidos em 5&#37; &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#44;05&#41; para todos os testes estat&#237;sticos&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Resultados</span><p id="par0110" class="elsevierStylePara elsevierViewall">A <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a> inclui os dados demogr&#225;ficos&#44; os tipos de HAI&#44; outras doen&#231;as autoimunes&#44; medicamentos e achados laboratoriais em pacientes com HAI&#46; A m&#233;dia de idade atual foi semelhante para os pacientes com HAI e controles saud&#225;veis &#91;13 anos &#40;5&#8208;18&#41; em compara&#231;&#227;o com 14 anos &#40;3&#8208;18&#41;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#44;804&#41;&#46; HAI tipo 1 foi observada em 57 pacientes &#40;971&#37;&#41;&#44; colangite esclerosante autoimune em 11 &#40;14&#37;&#41;&#44; HAI Tipo 2 em 10 &#40;12&#37;&#41; e aus&#234;ncia de autoanticorpos em dois &#40;2&#37;&#41;&#46; A comorbidade DMT1 foi observada em tr&#234;s pacientes &#40;4&#37;&#41; e a comorbidade cSLE em um &#40;1&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Ao avaliar as caracter&#237;sticas cl&#237;nicas de todos os pacientes entrevistados&#44; a queixa mais comum foi dor abdominal&#44; relatada por 20 pacientes com HAI &#40;25&#37;&#41;&#46; Somente um paciente se queixou de hipertricose como efeito colateral do uso de prednisona e n&#227;o houve queixas de ganho de peso ou estrias&#46; Foram detectados hist&#243;rico de hipertens&#227;o portal em sete pacientes &#40;58&#44;4&#37;&#41;&#44; de sangramento gastrointestinal superior em dois &#40;16&#44;6&#37;&#41; e de ascite em tr&#234;s &#40;25&#37;&#41;&#46; Remiss&#227;o foi observada em 62 &#40;77&#44;5&#37;&#41; pacientes com HAI&#8208;1 e HAI&#8208;2 e remiss&#227;o incompleta ou n&#227;o remiss&#227;o em 18 com HAI&#8208;1 &#40;22&#44;5&#37;&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">A <a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a> ilustra os escores dos pacientes do PedsQL 4&#46;0 em compara&#231;&#227;o com controles saud&#225;veis e escores dos pais em compara&#231;&#227;o com os pais dos controles&#46; Os escores f&#237;sico&#44; emocional&#44; escolar e total foram significativamente menores em pacientes com HAI em compara&#231;&#227;o com os controles saud&#225;veis&#46; Os escores f&#237;sico e total foram significativamente menores em pais dos indiv&#237;duos com HAI em compara&#231;&#227;o com os pais dos controles&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">A <a class="elsevierStyleCrossRef" href="#tbl0015">tabela 3</a> mostra a m&#233;dia dos escores f&#237;sico&#44; social e total em pacientes com HAI que apresentaram dor abdominal em compara&#231;&#227;o com os que n&#227;o apresentaram dor abdominal&#46; Foi observado um preju&#237;zo significativo na QVRS nos escores f&#237;sico&#44; social&#44; escolar e total em pacientes com HAI com dor abdominal com base no relato dos pais&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">A an&#225;lise dos pacientes com HAI em remiss&#227;o incompleta ou n&#227;o remiss&#227;o em compara&#231;&#227;o com os pacientes em remiss&#227;o revelou m&#233;dia de escores f&#237;sico&#44; emocional&#44; social&#44; escolar ou total n&#227;o significativa nos autorrelatos dos pacientes com HAI ou nos relatos dos pais dos pacientes com HAI&#46; Uma an&#225;lise com base na gravidade da doen&#231;a n&#227;o mostrou diferen&#231;as significativas em qualquer dom&#237;nio nos relatos dos pacientes ou dos pais&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Uma an&#225;lise adicional dos pacientes com HAI com base na dose de prednisona&#44; em que o grupo A tomou uma dose de prednisona de &#60; 0&#44;16<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;dia e o grupo B uma dose de prednisona de &#8805; 0&#44;16<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;dia&#44; revelou que o escore f&#237;sico foi significativamente menor no grupo B&#46; Nenhuma diferen&#231;a foi vista nos escores f&#237;sico&#44; emocional&#44; social&#44; escolar ou total entre os grupos de uso de dose de prednisona com base nos relatos dos pais &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabela 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discuss&#227;o</span><p id="par0140" class="elsevierStylePara elsevierViewall">O presente estudo &#233; a primeira investiga&#231;&#227;o da QVRS em pacientes pedi&#225;tricos com HAI na Am&#233;rica do Sul&#46; Encontramos escores reduzidos em quase todos os dom&#237;nios &#40;f&#237;sico&#44; emocional&#44; escolar e total&#41; em pacientes com HAI em compara&#231;&#227;o com os controles&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">As doen&#231;as cr&#244;nicas s&#227;o conhecidas por colocar a QVRS em risco em todas as idades e apesar de as crian&#231;as de um a tr&#234;s anos geralmente n&#227;o conseguirem se expressar verbalmente&#44; elas conseguem comunicar seus problemas&#46; Esses sinais n&#227;o devem ser subestimados durante a consulta cl&#237;nica&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">22</span></a> No caso de adolescentes&#44; uma melhoria na QVRS &#233; essencial na promo&#231;&#227;o de ades&#227;o ao tratamento&#46; Apesar dessa import&#226;ncia&#44; estima&#8208;se que menos de 25&#37; dos pediatras usam as medi&#231;&#245;es de qualidade de vida em suas consultas&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a> H&#225; um interesse cada vez maior na adapta&#231;&#227;o e cria&#231;&#227;o de instru&#231;&#227;o para medir a QVRS em crian&#231;as e adolescentes devido a um aumento na preval&#234;ncia de doen&#231;as cr&#244;nicas nessa faixa et&#225;ria&#46; A maior parte desses instrumentos &#233; quantitativa e muitos deles s&#227;o espec&#237;ficos para algumas doen&#231;as&#46; Um grande desafio &#233; incorporar as medi&#231;&#245;es de QVRS na pr&#225;tica cl&#237;nica&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">7</span></a> A qualidade de vida &#233; um conceito relacionado a aspectos culturais&#59; assim&#44; os instrumentos de medi&#231;&#227;o da QVRS devem ser adaptados a culturas e idiomas locais&#46; N&#227;o h&#225; um question&#225;rio espec&#237;fico para crian&#231;as e adolescentes com hepatite autoimune &#40;HAI&#41; e pouco se sabe sobre a QVRS desses pacientes&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">As principais vantagens do presente estudo s&#227;o a avalia&#231;&#227;o sistem&#225;tica da QVRS em crian&#231;as e adolescentes com hepatite autoimune com uma amostra relativamente grande&#44; apesar dos poucos estudos anteriores&#44; e a exclus&#227;o de pacientes submetidos a transplante de f&#237;gado&#44; pois essa doen&#231;a pode reduzir a QVRS&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a> Al&#233;m disso&#44; um grupo de controle saud&#225;vel com perfil de idade semelhante foi inclu&#237;do no presente estudo&#46; A principal limita&#231;&#227;o deste estudo foi o uso de somente uma ferramenta gen&#233;rica para medir a QVRS em crian&#231;as com HAI e seus pais&#46; Um poss&#237;vel vi&#233;s foi a compara&#231;&#227;o exclusiva com um grupo de controle saud&#225;vel&#59; contudo&#44; n&#227;o h&#225; dados publicados sobre a QVRS de crian&#231;as e adolescentes com doen&#231;a hep&#225;tica cr&#244;nica no Brasil para outras compara&#231;&#245;es&#46; Como nossa amostra foi composta de crian&#231;as de diferentes regi&#245;es do Brasil&#44; podemos usar um grupo de controle de qualquer regi&#227;o com confian&#231;a&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">As queixas dos pais com rela&#231;&#227;o a manifesta&#231;&#245;es cl&#237;nicas foram muito mal relatadas&#44; com exce&#231;&#227;o de dor abdominal&#44; que chamou nossa aten&#231;&#227;o&#46; Nossos dados confirmam os relatos anteriores de que dor abdominal est&#225; associada a redu&#231;&#227;o na QVRS&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a> Esse achado pode estar relacionado aos efeitos colaterais de agentes imunossupressores&#44; complica&#231;&#245;es da HAI ou mesmo manifesta&#231;&#227;o psicossom&#225;ticas&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Observamos que a dose de corticosteroide est&#225; associada a redu&#231;&#227;o nos escores f&#237;sicos em crian&#231;as e adolescentes com HAI&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a> Mesmo baixas doses de corticosteroides n&#227;o devem ser subestimadas&#44; pois esses medicamentos podem afetar a composi&#231;&#227;o corporal e hipertricose&#44; acne&#44; estrias&#44; ganho de peso e altera&#231;&#245;es no crescimento e&#44; assim&#44; afetar os escores da QVRS&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">26</span></a> Apesar dessas manifesta&#231;&#245;es n&#227;o terem sido observadas em nossa amostra&#44; os escores f&#237;sicos dos pacientes com HAI mostraram redu&#231;&#227;o&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Aproximadamente um quinto de nossos pacientes com HAI estava em remiss&#227;o incompleta no momento da entrevista&#44; apesar de essa vari&#225;vel n&#227;o influenciar a QVRS&#46; Esse achado tamb&#233;m foi observado na popula&#231;&#227;o adulta com HAI&#46; Portanto&#44; a QVRS poder&#225; ser reduzida em pacientes em remiss&#227;o&#44; bem como em pacientes que iniciam tratamento&#46; Esses achados corroboram a vis&#227;o de que a QVRS &#233; uma medida individual e subjetiva que deve ser considerada no tratamento individualizado de cada paciente&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">9&#44;22</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Um hist&#243;rico pr&#233;vio de complica&#231;&#245;es n&#227;o influenciou a QVRS de crian&#231;as ou adolescentes com HAI&#46; Os relatos dos pais revelaram escores de QVRS mais baixos somente no dom&#237;nio f&#237;sico&#44; um achado que difere de um relato anterior que sugere que todos os dom&#237;nios&#44; exceto o social&#44; foram prejudicados&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a> Adicionalmente&#44; a avalia&#231;&#227;o da QVRS pelos pais difere de pacientes em que quase todos os dom&#237;nios apresentam redu&#231;&#227;o&#46; Talvez os pais tenham confundido os sintomas emocionais dos filhos com sintomas f&#237;sicos e tenham interpretado de forma err&#244;nea tristeza como dor f&#237;sica&#46; Existe a possibilidade de que as diferen&#231;as culturais e socioecon&#244;micas entre nossa amostra de pais e a amostra no estudo anterior tenham levado a essa discrep&#226;ncia nos achados&#44; apesar de o instrumento ser validado para situa&#231;&#227;o cultural e socioecon&#244;mica&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">As doen&#231;as cr&#244;nicas na popula&#231;&#227;o pedi&#225;trica reduzem a QVRS&#44; principalmente doen&#231;as com dor f&#237;sica grave ou aquelas que exigem tratamentos mais agressivos&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a> Apesar de a HAI n&#227;o mostrar essas caracter&#237;sticas e geralmente responder bem a tratamento&#44; nossos resultados mostram uma redu&#231;&#227;o significativa na QVRS em todos os dom&#237;nios&#44; exceto social&#44; para pacientes com HAI em compara&#231;&#227;o com controles saud&#225;veis&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">10&#44;28</span></a> Para pacientes com HAI&#44; o tratamento de quaisquer sintomas f&#237;sicos que podem ocorrer n&#227;o elimina a doen&#231;a cr&#244;nica na inf&#226;ncia e adolesc&#234;ncia e o al&#237;vio dos sintomas f&#237;sicos n&#227;o necessariamente indica melhor QVRS&#46; Apesar de todos os dom&#237;nios testados estarem relacionados entre si&#44; ou seja&#44; caso o preju&#237;zo emocional afete o dom&#237;nio f&#237;sico&#44; os dom&#237;nios f&#237;sico e escolar devem ser mais investigados&#44; pois a HAI n&#227;o causa sintomas f&#237;sicos ou redu&#231;&#227;o cognitiva significativos&#46; Existe a possibilidade de faltas escolares causadas por consultas regulares de acompanhamento&#44; necess&#225;rias para exames m&#233;dicos&#44; poderem prejudicar o desempenho escolar&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Notavelmente&#44; uma pesquisa anterior indica que as crian&#231;as conseguem demonstrar seus pr&#243;prios sentimentos e queixas com uma avalia&#231;&#227;o confi&#225;vel de sua pr&#243;pria QVRS&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a> Assim&#44; instrumentos espec&#237;ficos para medir a QVRS em v&#225;rias doen&#231;as em crian&#231;as e adolescentes t&#234;m sido desenvolvidos e ser&#227;o necess&#225;rios estudos adicionais que avaliem novas ferramentas espec&#237;ficas para avaliar a QVRS em pacientes com HAI&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Escores reduzidos nos dom&#237;nios f&#237;sico&#44; emocional e escolar foram observados em pacientes pedi&#225;tricos com HAI&#46; Dor abdominal e dose de corticosteroide influenciaram negativamente a QVRS em crian&#231;as e adolescentes com HAI&#46; A gravidade da doen&#231;a e o estado de remiss&#227;o da doen&#231;a n&#227;o influenciaram a QVRS na popula&#231;&#227;o pedi&#225;trica com HAI&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Por fim&#44; nossos resultados destacam a urg&#234;ncia de dar aten&#231;&#227;o a sintomas f&#237;sicos&#44; escolares e emocionais de pacientes com HAI e ao desenvolvimento de um instrumento espec&#237;fico de medi&#231;&#227;o da QVRS para crian&#231;as e adolescentes com HAI&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflitos de interesse</span><p id="par0195" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflitos de interesse&#46;</p></span></span>"
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          "titulo" => "Pacientes e m&#233;todos"
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              "titulo" => "Amostra"
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              "titulo" => "Grupo de controle"
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              "titulo" => "Avalia&#231;&#245;es da QVRS"
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              "titulo" => "Avalia&#231;&#245;es demogr&#225;ficas&#44; cl&#237;nicas&#44; laboratoriais e terap&#234;uticas"
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              "identificador" => "sec0035"
              "titulo" => "Dose de prednisona"
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    "fechaRecibido" => "2017-07-26"
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            0 => "Quality of life"
            1 => "Autoimmune hepatitis"
            2 => "Childhood"
            3 => "Adolescence"
            4 => "Chronic disease"
            5 => "PedsQL 4&#46;0"
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          "palabras" => array:6 [
            0 => "Qualidade de vida"
            1 => "Hepatite autoimune"
            2 => "Inf&#226;ncia"
            3 => "Adolesc&#234;ncia"
            4 => "Doen&#231;a cr&#244;nica"
            5 => "PedsQL 4&#46;0"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The objective of this study was to evaluate the health&#8208;related quality of life in children and adolescents with autoimmune hepatitis&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A cross&#8208;sectional assessment with the Pediatric Quality of Life Inventory 4&#46;0 &#40;PedsQL 4&#46;0&#41; was completed for 80 patients with autoimmune hepatitis and 45 healthy controls&#46; Demographic data&#44; prednisone dose&#44; disease remission state&#44; disease severity&#44; and abdominal pain were also evaluated&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Based on the child self&#8208;reports&#44; physical&#44; emotional&#44; school&#44; and total scores were significantly lower in autoimmune hepatitis patients when compared with controls &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Based on the parental reports&#44; only the physical and total scores were significantly lower in autoimmune hepatitis patients <span class="elsevierStyleItalic">versus</span> controls &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Further analysis in autoimmune hepatitis patients with abdominal pain in the last month revealed significantly lower physical&#44; social&#44; and total median scores &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; No differences were observed based on disease remission state or disease severity &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Autoimmune hepatitis patients who received a prednisone dose below 0&#46;16<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day at the time of the interview showed significantly higher physical scores than those who received a dose similar to or above 0&#46;16<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day &#40;87&#46;5 &#91;50&#8211;100&#93; <span class="elsevierStyleItalic">vs</span>&#46; 75 &#91;15&#46;63&#8211;100&#93;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;006&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Reduced scores in the physical&#44; emotional&#44; and school domains were observed in pediatric autoimmune hepatitis patients compared to control patients&#46; Abdominal pain and corticosteroid dose negatively influenced the health&#8208;related quality of life in children and adolescents with autoimmune hepatitis&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Avaliar a qualidade de vida relacionada &#224; sa&#250;de em crian&#231;as e adolescentes com hepatite autoimune &#40;HAI&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Foi conclu&#237;da uma avalia&#231;&#227;o transversal com o Invent&#225;rio Pedi&#225;trico de Qualidade de Vida 4&#46;0 &#40;PedsQL 4&#46;0&#41; para 80 pacientes com hepatite autoimune e 45 controles saud&#225;veis&#46; Os dados demogr&#225;ficos&#44; a dose de prednisona&#44; o estado de remiss&#227;o da doen&#231;a&#44; a gravidade da doen&#231;a e dor abdominal tamb&#233;m foram avaliados&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Com base nos autorrelatos das crian&#231;as&#44; os escores f&#237;sico&#44; emocional&#44; escolar e total foram significativamente menores em pacientes com hepatite autoimune em compara&#231;&#227;o com os controles &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#44;05&#41;&#46; Com base nos relatos dos pais&#44; apenas os escores f&#237;sico e total foram significativamente menores em pacientes com hepatite autoimune em compara&#231;&#227;o com os controles &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#44;05&#41;&#46; Uma an&#225;lise adicional em pacientes com hepatite autoimune com dor abdominal no m&#234;s passado revelou escores m&#233;dios f&#237;sico&#44; social e total significativamente menores &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#44;05&#41;&#46; Nenhuma diferen&#231;a foi observada com base no estado de remiss&#227;o da doen&#231;a ou na gravidade da doen&#231;a &#40;<span class="elsevierStyleItalic">p</span> &#62; 0&#44;05&#41;&#46; Os pacientes com hepatite autoimune que receberam uma dose de prednisona abaixo de 0&#44;16<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;dia no momento da entrevista mostraram escores f&#237;sicos significativamente maiores que os que receberam uma dose semelhante ou acima de 0&#44;16<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;dia &#91;87&#44;5 &#40;50&#8208;100&#41; em compara&#231;&#227;o com 75 &#40;15&#44;63&#8208;100&#41;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#44;006&#93;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Escores reduzidos nos dom&#237;nios f&#237;sico&#44; emocional e escolar foram observados em pacientes pedi&#225;tricos com hepatite autoimune em compara&#231;&#227;o com pacientes do grupo de controle&#46; Dor abdominal e dose de corticosteroide influenciaram negativamente a qualidade de vida relacionada &#224; sa&#250;de em crian&#231;as e adolescentes com hepatite autoimune&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Como citar este artigo&#58; Bozzini AB&#44; Neder L&#44; Silva CA&#44; Porta G&#46; Decreased health&#8208;related quality of life in children and adolescents with autoimmune hepatitis&#46; J Pediatr &#40;Rio J&#41;&#46; 2019&#59;95&#58;87&#8211;93&#46;</p>"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Os resultados s&#227;o apresentados em mediana &#40;intervalo&#41; e n &#40;&#37;&#41;&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Vari&#225;veis no in&#237;cio do estudo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pacientes com HAI &#40;n &#61; 80&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Dados demogr&#225;ficos</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Idade atual&#44; anos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13 &#40;5&#8208;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sexo feminino&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56 &#40;70&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Dura&#231;&#227;o da doen&#231;a&#44; anos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#44;9 &#40;3&#44;06&#8208;4&#44;75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Tipo de hepatite autoimune</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>HAI&#8208;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57 &#40;71&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>HAI e colangite esclerosante autoimune &#40;s&#237;ndrome da sobreposi&#231;&#227;o&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11 &#40;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>HAI&#8208;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Aus&#234;ncia de autoanticorpos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Outra doen&#231;a autoimune</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Diabetes mellitus tipo 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>L&#250;pus eritematoso sist&#234;mico de in&#237;cio na inf&#226;ncia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Medicamentos</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Somente prednisona&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Prednisona e azatioprina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55 &#40;69&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Prednisona e outros medicamentos imunossupressores&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sem tratamento&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Achados laboratoriais</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>AST&#44;U&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">36&#40;13&#8208;5205&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ALT&#44;U&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">36&#44;5&#40;8&#8208;1119&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>GGT&#44;U&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">41&#44;5&#40;10&#8208;941&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ALP&#44;U&#47;l&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">159&#40;9&#8208;473&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>INR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;16&#40;0&#44;96&#8208;2&#44;03&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bilirrubina&#44; mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;71&#40;0&#44;21&#8208;13&#44;65&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Albumina&#44; g&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#40;2&#44;93&#8208;15&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Vari&#225;veis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sem dor abdominal &#40;n &#61; 60&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Com dor abdominal &#40;n &#61; 20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Crian&#231;as com HAI</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>F&#237;sico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84&#44;37 &#40;50&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&#44;18 &#40;15&#44;63&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Emocional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65 &#40;20&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&#44;50 &#40;5&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;701&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Social&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100 &#40;20&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">85 &#40;30&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Escolar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75 &#40;20&#44;8&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&#44;98 &#40;36&#44;61&#8208;97&#44;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;262&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">79&#44;13 &#40;37&#44;54&#8208;96&#44;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">69&#44;98 &#40;36&#44;61&#8208;97&#44;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1943354.png"
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            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pais de crian&#231;as com HAI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#40;n &#61; 42&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#40;n &#61; 16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>F&#237;sico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87&#44;50 &#40;43&#44;75&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75 &#40;3&#44;13&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Emocional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65 &#40;25&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70 &#40;5&#8208;95&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;910&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Social&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100 &#40;20&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95 &#40;10&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;027&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Escolar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">85 &#40;55&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&#44;50&#40;20&#8208;95&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">81&#44;79 &#40;57&#44;97&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72&#44;50 &#40;35&#44;47&#8208;93&#44;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1943355.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Escores do Invent&#225;rio Pedi&#225;trico de Qualidade de Vida 4&#46;0 &#40;PedsQL 4&#46;0&#41; de crian&#231;as e adolescentes com hepatite autoimune &#40;HAI&#41; e seus pais&#44; de acordo com a presen&#231;a de dor abdominal</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Tabela 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at4"
            "detalle" => "Tabela "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Os resultados s&#227;o apresentados em mediana &#40;intervalo&#41; pelo teste de Mann&#8208;Whitney&#46;</p>"
          "tablatextoimagen" => array:2 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pacientes com HAI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Grupo A<br>&#40;n &#61; 37&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Grupo B<br>&#40;n &#61; 38&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">F&#237;sico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87&#44;5 &#40;50&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75 &#40;15&#44;63&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Emocional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65 &#40;25&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">62&#44;5 &#40;5&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;675&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Social&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60 &#40;100&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90 &#40;20&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;063&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Escolar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75 &#40;35&#8208;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72&#44;5 &#40;20&#44;8&#8208;90&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;205&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72&#44;40 &#40;67&#44;42&#8208;77&#44;38&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">79&#44;54 &#40;76&#8208;83&#44;07&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;055&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1943353.png"
              ]
            ]
            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pais de crian&#231;as com HAI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Grupo A<br>&#40;n &#61; 23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Grupo B<br>&#40;n &#61; 31&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">F&#237;sico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">86&#44;41 &#40;81&#44;09&#8208;91&#44;73&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74&#44;63 &#40;66&#44;36&#8208;82&#44;90&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;056&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Emocional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&#44;60 &#40;58&#44;36&#8208;76&#44;84&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63&#44;22 &#40;54&#44;86&#8208;71&#44;58&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;434&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Social&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91&#44;95 &#40;85&#44;18&#8208;98&#44;72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">89&#44;83 &#40;81&#44;79&#8208;97&#44;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;965&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Escolar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">79&#44;13 &#40;71&#44;70&#8208;86&#44;55&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77&#44;31 &#40;72&#44;53&#8208;82&#44;08&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;578&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">81&#44;27 &#40;76&#44;66&#8208;85&#44;89&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">76&#44;25 &#40;70&#44;83&#8208;81&#44;67&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;290&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1943350.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Escores do Invent&#225;rio Pedi&#225;trico de Qualidade de Vida 4&#46;0 &#40;PedsQL 4&#46;0&#41; de crian&#231;as e adolescentes de acordo com a mediana da dose de prednisona no momento da entrevista&#58; Grupo A &#40;&#60; 0&#44;16<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;dia&#41; em compara&#231;&#227;o com o Grupo B &#40;&#8805; 0&#44;16<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;dia&#41;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "Refer&#234;ncias"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:29 [
            0 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The management of childhood liver diseases in adulthood"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "D&#46; Joshi"
                            1 => "N&#46; Gupta"
                            2 => "M&#46; Samyn"
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