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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">Las lesiones traum&#225;ticas constituyen un importante problema de salud p&#250;blica en los pa&#237;ses desarrollados&#44; siendo la principal causa de muerte en j&#243;venes menores de 45 a&#241;os y la quinta en el conjunto de todas las edades<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Las lesiones traum&#225;ticas&#44; muy especialmente las derivadas de los accidentes de tr&#225;fico&#44; generan un alto coste econ&#243;mico desde la fase inicial de su asistencia prehospitalaria hasta completarse la fase final de rehabilitaci&#243;n<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">El objetivo principal que se marca un sistema de cuidado traumatol&#243;gico es disminuir la mortalidad pero un objetivo m&#225;s ambicioso es conseguir la reintegraci&#243;n personal&#44; familiar y social&#44; ya que las lesiones generan importantes discapacidades en los pacientes que sobreviven a un traumatismo<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46; Por tanto&#44; se hace imprescindible valorar la repercusi&#243;n de las lesiones traum&#225;ticas sobre la calidad de vida relacionada con la salud &#40;CVRS&#41;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Los pacientes con patolog&#237;a traum&#225;tica presentan unas caracter&#237;sticas diferenciales sobre el resto de los pacientes ingresados en las unidades de cuidados intensivos &#40;UCI&#41;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; Generalmente son personas j&#243;venes&#44; sin comorbilidades asociadas y en los que las lesiones traum&#225;ticas generan importantes deficiencias&#44; discapacidades y minusval&#237;as<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46; Probablemente todos estos conceptos son mucho m&#225;s amplios que la simple interpretaci&#243;n de las variables vivo o muerto para evaluar el resultado final a largo plazo de la asistencia a estos pacientes&#46; El conocimiento de la calidad de vida proporciona informaci&#243;n general sobre la salud f&#237;sica&#44; mental y social&#46; Tambi&#233;n nos informa de c&#243;mo estas discapacidades afectan a aspectos de bienestar&#44; como la percepci&#243;n de un individuo con relaci&#243;n a los objetivos&#44; expectativas en su vida e impacto psicol&#243;gico<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">A pesar del creciente inter&#233;s&#44; no hay muchos estudios realizados espec&#237;ficamente en la poblaci&#243;n traum&#225;tica ingresada en UCI<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a>&#46; The European Consumer Safety Association &#40;ECOSA&#41; cre&#243; un grupo para establecer las gu&#237;as de trabajo para cuantificar el grado de discapacidad y el deterioro en la calidad de vida de los pacientes traum&#225;ticos tras una exhaustiva revisi&#243;n bibliogr&#225;fica entre los a&#241;os 1995-2005&#46; Aunque en estas gu&#237;as publicadas en 2007 se recomendaba como cuestionarios de salud el EQ-5D y en segundo lugar el SF-36&#44; los estudios que se han realizado hasta la fecha han utilizado cuestionarios muy diversos &#40;SIP&#44; QWB&#44; QoL-Bref&#44; NPH&#44; etc&#46;&#41;&#46; Igualmente ECOSA recomend&#243; realizar estudios longitudinales para poder establecer la evoluci&#243;n temporal en las diferentes fases de la recuperaci&#243;n de un traumatismo&#46; Se establece una clasificaci&#243;n temporal con una fase inicial de tratamiento agudo &#40;0-8 semanas&#41;&#44; fase de rehabilitaci&#243;n &#40;1-3 meses&#41;&#44; fase de adaptaci&#243;n &#40;3-6 meses&#41; y finalmente una fase final de estabilidad &#40;6-24 meses&#41;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Los objetivos de nuestro trabajo son conocer la CVRS de los pacientes traum&#225;ticos ingresados en nuestra UCI&#44; tanto previa como en su evoluci&#243;n a los 6 y 12 meses mediante los instrumentos de medida EQ-5D y SF-36 y determinar los factores de riesgo que condicionan una peor CVRS al a&#241;o del alta&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pacientes y m&#233;todo</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pacientes</span><p id="par0035" class="elsevierStylePara elsevierViewall">Estudio prospectivo en una UCI polivalente de un hospital universitario de referencia de 450 camas de segundo nivel siendo centro de referencia provincial para la asistencia del paciente neurocr&#237;tico&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Se analizaron todos los pacientes traumatizados ingresados de forma consecutiva entre el 1 de enero de 2005 y el 31 de diciembre de 2006 en nuestra UCI&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Se incluyeron todos los pacientes supervivientes mayores de 16 a&#241;os y con una estancia en UCI superior a 24<span class="elsevierStyleHsp" style=""></span>h&#46; 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Seg&#250;n regi&#243;n corporal implicada&#44; los pacientes se clasificaron como traumatismo grave&#58; craneoencef&#225;lico &#40;TCE&#41;&#44; tor&#225;cico&#44; abdominal o de extremidades que incluye tanto superiores como inferiores con una puntuaci&#243;n de AIS<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>3<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Se recogieron procedimientos como ventilaci&#243;n mec&#225;nica&#44; necesidad de noradrenalina&#44; utilizaci&#243;n de nutrici&#243;n parenteral&#44; variables cl&#237;nicas de seguimiento como estancia y mortalidad en UCI y hospitalaria&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">El estudio recibi&#243; la aprobaci&#243;n institucional del Comit&#233; &#201;tico de Investigaci&#243;n cl&#237;nica del hospital&#46; Todos los participantes dieron su consentimiento informado para ser incluidos para su seguimiento&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Encuestas de calidad de vida</span><p id="par0065" class="elsevierStylePara elsevierViewall">Utilizamos los cuestionarios gen&#233;ricos de salud EQ-5D y SF-36 en sus versi&#243;n espa&#241;ola&#44; ya validada en nuestro &#225;mbito de intensivos por nuestro grupo en un estudio anterior<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">El cuestionario EQ-5D valora el estado de salud en 5 dimensiones&#58; movilidad&#44; cuidado personal&#44; actividades cotidianas&#44; dolor&#47;malestar y ansiedad&#47;depresi&#243;n con 3 niveles de gravedad en cada dimensi&#243;n&#46; Incluye tambi&#233;n una escala visual anal&#243;gica &#40;EVA&#41; de valoraci&#243;n general y la obtenci&#243;n de un &#237;ndice o tarifa generado por el estado de salud obtenido<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">El SF-36 contiene 36 &#237;tems que se miden en 8 dimensiones &#40;funci&#243;n f&#237;sica&#44; rol f&#237;sico&#44; rol emocional&#44; funci&#243;n social&#44; dolor corporal&#44; salud mental&#44; vitalidad y salud general&#41; obteniendo una puntuaci&#243;n del 0 al 100&#44; de tal manera que a mayor puntuaci&#243;n mejor estado de salud percibida&#46; Tambi&#233;n se calcul&#243; el componente f&#237;sico &#40;CF&#41; y el componente mental &#40;CM&#41; obtenidos a partir de las 8 dimensiones<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Calidad de vida pre y postunidad de cuidados intensivos &#40;6 y 12 meses&#41;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Para evaluar la calidad de vida previa al ingreso en UCI&#44; referida a 4 semanas antes del ingreso en UCI&#44; se realizaron las 2 encuestas &#40;EQ-5D y SF-36&#41; al alta de la UCI o dentro de las primeras 48<span class="elsevierStyleHsp" style=""></span>h de estancia posterior en planta de hospitalizaci&#243;n&#46; Se insist&#237;a en que el paciente cumplimentara los cuestionarios por s&#237; mismo&#59; se permiti&#243; ayuda por un familiar pr&#243;ximo solamente cuando el paciente era incapaz de leer las preguntas o de escribir las respuestas&#46; Las encuestas post-UCI se realizaron a los 6 y 12 meses del alta de la unidad&#46; Se contactaba por tel&#233;fono y los pacientes se citaban para acudir a nuestra consulta&#46; Las encuestas se realizaban bajo la supervisi&#243;n de un m&#233;dico entrenado que ofrec&#237;a las explicaciones previas antes de ser autoadministradas&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Se defini&#243; una mala CVRS previa como la obtenci&#243;n de una EVA inferior al percentil 25 y a los 12 meses cuando el valor de EVA no superaba el percentil 50 de la muestra&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Metodolog&#237;a estad&#237;stica</span><p id="par0090" class="elsevierStylePara elsevierViewall">El an&#225;lisis estad&#237;stico descriptivo incluy&#243; media &#40;desviaci&#243;n est&#225;ndar&#41;&#44; mediana &#40;intervalo intercuartil&#41;&#44; o porcentaje seg&#250;n las caracter&#237;sticas de las variables&#46; Las dimensiones del SF-36 se expresan como media &#40;desviaci&#243;n est&#225;ndar&#41;&#44; y las del EQ-5D como porcentaje de problemas&#46; Para la comparaci&#243;n de los datos cl&#237;nicos y demogr&#225;ficos del grupo de estudio se utiliz&#243; el test estad&#237;stico de &#967;<span class="elsevierStyleSup">2</span> para variables categ&#243;ricas&#44; y para las variables continuas el test no param&#233;trico de Kruskal-Wallis &#40;variables no relacionadas&#41; o el test de Friedman &#40;variables relacionadas&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Se realiz&#243; un an&#225;lisis de factores de riesgo de mala CVRS a los 12 meses calculando las odds ratio &#40;OR&#41; &#40;y sus intervalos de confianza al 95&#37;&#41; de forma univariante y mediante un modelo multivariante &#40;regresi&#243;n log&#237;stica m&#250;ltiple con selecci&#243;n autom&#225;tica de variables por pasos&#41; incorporando en el modelo inicial aquellos factores significativos univariantes&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">El nivel de significaci&#243;n estad&#237;stica aceptado fue del 5&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; Se emple&#243; el paquete estad&#237;stico SPSS &#40;versi&#243;n 15&#46;0&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Resultados</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pacientes</span><p id="par0105" class="elsevierStylePara elsevierViewall">Durante el periodo de estudio ingresaron 213 pacientes de causa traum&#225;tica en la UCI &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; El mes previo al inicio del estudio se realiz&#243; una prueba piloto con 10 pacientes que cumplimentaron las 2 encuestas &#40;EQ-5D y SF-36&#41; pero no se incluyeron finalmente en el estudio&#46; La mortalidad de los pacientes traum&#225;ticos fue del 21&#37; &#40;45 pacientes&#41;&#46; Se excluyeron 38 pacientes &#40;12 por problemas de idioma y 26 por deterioro cognitivo secundario a TCE&#41;&#46; El grupo potencial de respuesta fueron 130 pacientes y respondieron 110 pacientes &#40;porcentaje de respuesta del 84&#37;&#41;&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se muestran las caracter&#237;sticas demogr&#225;ficas del grupo de estudio&#46; Los pacientes traum&#225;ticos presentaron una edad media de 41&#44;7 a&#241;os&#44; siendo significativamente m&#225;s j&#243;venes los pacientes del grupo excluidos&#44; hubo un predominio de varones &#40;75&#44;6&#37;&#41; y el accidente de tr&#225;fico fue la causa m&#225;s frecuente del traumatismo con el TCE y el de t&#243;rax como las 2 &#225;reas anat&#243;micas m&#225;s afectadas&#46; El nivel de gravedad seg&#250;n el APACHE II fue 10 &#40;7-15&#41; con un ISS de 17 &#40;10-25&#41; y estancia en UCI de 8 &#40;4-21&#41; d&#237;as sin detectar diferencias entre los tres grupos&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Evoluci&#243;n en la calidad de vida &#40;previa&#44; 6 y 12 meses&#41;</span><p id="par0110" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a> se muestran las puntuaciones de las 8 dimensiones del SF-36 &#40;previa al ingreso en UCI&#44; 6 y 12 meses&#41; y en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a> los porcentajes de problemas seg&#250;n dimensi&#243;n del EQ-5D &#40;con EVA y tarifa&#41;&#46; Se compararon seg&#250;n sexo&#44; edad y zona anat&#243;mica afectada&#46; Las mujeres presentaron peores valores tanto previos como en el seguimiento a los 6 y 12 meses del traumatismo&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">La calidad de vida mostr&#243; un deterioro general en todas las dimensiones de ambos cuestionarios como se observa en las <a class="elsevierStyleCrossRef" href="#fig0010">figura 2</a>A y 2B&#46; Se aprecia una mayor repercusi&#243;n en las dimensiones f&#237;sicas&#46; En la <a class="elsevierStyleCrossRef" href="#fig0015">figura 3</a> se observa la evoluci&#243;n de los componentes f&#237;sico y metal del SF-36 &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>A y B&#41; y EVA del EQ-5D &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>C&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">El CF y CM sufrieron un descenso significativo al a&#241;o del alta de UCI&#46; Aunque el deterioro a los 6 meses fue mayor para el CM&#44; su recuperaci&#243;n al a&#241;o del alta fue mejor que en el CF pero sin llegar a conseguir los valores previos al accidente&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Factores de riesgo de mala calidad de vida a los 12 meses</span><p id="par0125" class="elsevierStylePara elsevierViewall">El punto de corte de EVA a los 12 meses que defini&#243; la existencia de una mala CVRS fue de 65&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a> se muestran las diferencias entre los grupos seg&#250;n este punto de corte&#46; Los pacientes con peor CVRS fueron m&#225;s mayores&#44; con mayor porcentaje de mujeres&#44; mayor nivel de gravedad y mayor estancia en UCI y hospitalaria&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">Inicialmente para determinar los factores relacionados con una peor CVRS a los 12 meses &#40;definida como EVA menor de 65&#41; se realiz&#243; un an&#225;lisis de regresi&#243;n log&#237;stica univariante obteniendo como variables predictoras&#58; edad superior a 45 a&#241;os 3&#44;2&#40;1&#44;4-1&#44;7&#41;&#44; mujer 3&#44;1&#40;1&#44;2-7&#44;6&#41;&#44; nutrici&#243;n parenteral total 3&#44;8 &#40;1&#44;6-9&#44;1&#41;&#44; APACHE II<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>15 3&#44;3 &#40;1&#44;1-10&#44;8&#41;&#44; ISS<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>25 2&#44;5 &#40;1&#44;1-14&#44;8&#41;&#44; TRISS<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>10 2&#44;9 &#40;1&#44;2-7&#44;4&#41;&#44; estancia &#8805; 7 3&#44;9 &#40;1&#44;7-8&#44;9&#41;&#44; EVA previa &#8804;<span class="elsevierStyleHsp" style=""></span>3&#44;5 &#40;1&#44;4-9&#44;0&#41; y extremidades &#8805;<span class="elsevierStyleHsp" style=""></span>3 2&#44;7 &#40;1&#44;2-7&#44;2&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">En el an&#225;lisis multivariable las variables que obtuvieron significaci&#243;n estad&#237;stica fueron un TRISS mayor de 10&#44; tener una EVA previa menor o igual a 85 &#40;percentil 25 de la muestra&#41; y tener una afectaci&#243;n grave de extremidades &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discusi&#243;n</span><p id="par0140" class="elsevierStylePara elsevierViewall">Nuestros resultados muestran que los pacientes que logran superar el ingreso en UCI evidencian un deterioro de su calidad de vida en todas las dimensiones evaluadas a los 6 meses&#44; con una mejor&#237;a a los 12 meses&#44; aunque sin llegar a igualar su estado previo valorado en ambos cuestionarios&#46; Los pacientes presentan un descenso de las funciones f&#237;sicas y sociales&#44; un incremento del dolor corporal&#44; menor vitalidad y un descenso del estado de salud general y mental&#46; Seg&#250;n el cuestionario SF- 36&#44; la dimensi&#243;n que m&#225;s se deteriora en el paciente con un traumatismo grave al a&#241;o es el rol f&#237;sico aunque el conjunto del componente mental disminuye m&#225;s&#44; en los primeros 6 meses&#44; que el componente f&#237;sico&#46; Debemos recordar que el grupo de pacientes traum&#225;ticos que sobreviven a un ingreso en UCI est&#225; constituido principalmente por pacientes j&#243;venes que presentaban una CVRS previa excelente<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Otros estudios publicados han comprobado que de los pacientes ingresados en UCI&#44; el subgrupo de pacientes traum&#225;ticos son los que sufren un mayor deterioro de su CVRS<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;20</span></a>&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">El estudio multivariante muestra que los factores que influyen en una peor CVRS son la edad&#44; la calidad de vida previa&#44; la gravedad al ingreso y las lesiones graves de las extremidades&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">En la mayor&#237;a de los estudios&#44; la edad se muestra como un factor determinante en el empeoramiento de la calidad de vida y tienen una peor recuperaci&#243;n en la evoluci&#243;n posterior a los 12 meses<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;21</span></a>&#46; En el estudio de V&#225;zquez Mata et al&#46; la edad se mostr&#243; como el factor que m&#225;s influy&#243; en una peor calidad de vida<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46; A medida que aumenta la edad&#44; el deterioro es mayor y de forma m&#225;s acusada en aquellas dimensiones que valoran la capacidad f&#237;sica<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;23</span></a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Destacar en el an&#225;lisis multivariable que las mujeres no presentan peores valores de su calidad de vida en todas las dimensiones respecto a los hombres aunque existe una tendencia<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;24</span></a>&#46; En la mayor&#237;a de los trabajos s&#237; que se obtienen estas diferencias seg&#250;n el g&#233;nero<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">En el an&#225;lisis multivariante&#44; al igual que en el estudio de Vazquez Mata et al&#46;&#44; la CVRS previa al accidente se muestra como un factor determinante de un mayor deterioro de CVRS al a&#241;o del accidente<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">M&#225;s controvertida es la relaci&#243;n de la gravedad del traumatismo con el deterioro en la CVRS&#46; Aunque los scores de gravedad se dise&#241;aron como &#237;ndices predictores de mortalidad&#44; algunos autores han observado una buena correlaci&#243;n en el deterioro de la CVRS&#44; tanto en los scores generales &#40;APACHE II y SAPS II&#41; como en scores espec&#237;ficos &#40;ISS&#41;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;25&#8211;28</span></a>&#46; Por el contrario&#44; otros estudios no logran demostrar que una mayor gravedad al ingreso tenga que relacionarse con un mayor deterioro de su CVRS<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;29&#8211;31</span></a>&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Destacar que en UCI ingresan pacientes con diferentes niveles de gravedad y en ocasiones el objetivo es la vigilancia de lesiones que potencialmente pueden amenazar la vida del paciente &#40;traumatismos tor&#225;cicos o de v&#237;scera maciza&#44; etc&#46;&#41;&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">En un estudio sobre 507 pacientes que hab&#237;an sufrido un accidente de tr&#225;fico con un 76&#37; de lesiones menores&#44; el 26&#37; de los pacientes padec&#237;an s&#237;ntomas psicol&#243;gicos y un 21&#37; ten&#237;an dolores moderados o severos tras 3 a&#241;os de seguimiento<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a>&#46; Seg&#250;n Brasel et al&#46; parece existir una fuerte correlaci&#243;n entre la gravedad de las lesiones seg&#250;n el ISS y la afectaci&#243;n de las dimensiones f&#237;sicas en la fase inicial postraumatismo pero no se relaciona con deterioro de las dimensiones mentales tanto al inicio como en el seguimiento posterior a los 6 meses<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&#46; Nuestro estudio encuentra que los pacientes m&#225;s graves &#40;medidos con la escala TRISS&#41; tienen peor CVRS al a&#241;o del alta de UCI&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Algunos estudios han demostrado la influencia del &#225;rea anat&#243;mica afectada en la CVRS posterior&#46; En el trabajo de Holtslag et al&#46; se realiza un seguimiento entre 12-18 meses de 335 pacientes con un ISS<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>15&#44; demostrando que las &#225;reas anat&#243;micas que influyen de forma independiente en la recuperaci&#243;n posterior son los TCE&#44; la lesiones de la columna vertebral y las lesiones de las extremidades inferiores<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&#46; En nuestro trabajo coincidimos en que las lesiones m&#225;s graves de las extremidades se asocian con una peor recuperaci&#243;n tanto a los 6 como a los 12 meses&#44; aunque no podemos evaluar a los pacientes con lesiones medulares al ser trasladados a centros de referencia<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;28</span></a>&#46; Adem&#225;s esta recuperaci&#243;n suele ser m&#225;s lenta que la observada en lesiones de otras &#225;reas anat&#243;micas<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;31</span></a>&#46; Este es un factor que se debe tener en cuenta para poder programar las diferentes fases de rehabilitaci&#243;n del paciente con un mismo nivel de gravedad seg&#250;n el &#225;rea lesionada y si existe lesi&#243;n grave de las extremidades&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Existe controversia sobre si el TCE es un factor determinante en el deterioro de la calidad de vida&#46; Aunque varios estudios han establecido el TCE como un factor independiente en el deterioro de la calidad de vida<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;33</span></a> otros estudios no hallan esta relaci&#243;n<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;25</span></a>&#46; En nuestro modelo&#44; la presencia de un TCE severo no se comporta como una variable independiente&#46; Varias causas pueden justificar estos resultados&#46; Los TCE con alteraciones cognitivas son motivo de exclusi&#243;n del trabajo y coincidimos con las recomendaciones de Mackenzie de que en los pacientes con traumatismo craneal debe a&#241;adirse al cuestionario general una evaluaci&#243;n de la funci&#243;n cognitiva<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>&#46; Si un paciente tiene un deterioro de la funci&#243;n cognitiva puede tener alterada la percepci&#243;n del deterioro funcional e incluso en algunos casos la percepci&#243;n es que mejora respecto a la calidad de vida previa&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Aunque las lesiones abdominales y tor&#225;cicas son una de las principales causa de muerte en la fase inicial de la asistencia al traumatismo grave&#44; los resultados a largo plazo son buenos sin deteriorarse la CVRS<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a>&#46; Por otro lado&#44; Kiely et al&#46; con una poblaci&#243;n de pacientes traum&#225;ticos &#40;ISS<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>9&#41; observan que las 2 &#225;reas que m&#225;s deterioran la calidad de vida al mes del traumatismo son las extremidades y el t&#243;rax&#59; por el contrario&#44; a los 6 meses el TCE es el que determina una peor evoluci&#243;n<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a>&#46; Todo ello dificulta que se llegue a un consenso sobre el tiempo id&#243;neo de seguimiento<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;29&#44;36</span></a>&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Otros factores como las complicaciones adquiridas durante su ingreso y la estancia hospitalaria se han relacionado con el resultado final<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;21&#44;29</span></a>&#46; En nuestro caso coincidimos con otros estudios en que los d&#237;as de estancia no se asocian con el deterioro de la calidad de vida<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;37</span></a>&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Nuestro estudio tiene varias limitaciones&#46; El trabajo fue realizado en una sola UCI&#44; con las caracter&#237;sticas espec&#237;ficas de nuestro hospital&#46; En nuestro centro los pacientes que presentan lesiones de la columna vertebral son trasladados a un centro de referencia y no han podido ser evaluados&#46; Ser&#237;an deseables estudios multic&#233;ntricos y con un mayor n&#250;mero de pacientes&#46; La exclusi&#243;n de los pacientes con deterioro cognitivo adquirido no permite evaluar en toda su magnitud a los pacientes con TCE ni tampoco se ha realizado ninguna evaluaci&#243;n espec&#237;fica del deterioro cognitivo&#46; El periodo de seguimiento de un a&#241;o podr&#237;a ser insuficiente para valorar la recuperaci&#243;n en todas las dimensiones&#44; aunque no existen recomendaciones claras a este respecto&#59; valoraciones m&#225;s all&#225; de 18-24 meses no est&#225;n suficientemente validadas&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">En resumen&#44; los pacientes ingresados en las UCI sufren un marcado deterioro de su CVRS&#46; Se deben seguir haciendo estudios longitudinales que eval&#250;en la evoluci&#243;n de la calidad de vida de los pacientes traum&#225;ticos supervivientes de un ingreso en UCI y obtener una visi&#243;n global del problema&#46; Se deben realizar m&#225;s estudios que determinen los tiempos de seguimiento en funci&#243;n de las &#225;reas anat&#243;micas afectadas y del paciente politraumatizado en general ingresado en la UCI&#46; Debe analizarse el grado de deterioro cognitivo tras sufrir un TCE y c&#243;mo este influye en un posible deterioro de la CVRS&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">La detecci&#243;n de factores que permitan predecir qu&#233; pacientes van a presentar una peor calidad de vida &#40;edad&#44; gravedad&#44; CVRS previa y lesiones graves de las extremidades&#41; puede ser de utilidad para un abordaje asistencial adaptado a las necesidades de cada situaci&#243;n cl&#237;nica&#44; logrando unos cuidados sanitarios de calidad y mejorando el pron&#243;stico de estos pacientes&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicto de intereses</span><p id="par0220" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec284787"
          "palabras" => array:5 [
            0 => "Calidad de vida relacionada con la salud"
            1 => "Short Form SF-36"
            2 => "EuroQoL 5D"
            3 => "Politraumatizado"
            4 => "Cuidados intensivos"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec284788"
          "palabras" => array:5 [
            0 => "Health-related quality of life"
            1 => "Short Form SF-36"
            2 => "EuroQoL 5D"
            3 => "Major trauma"
            4 => "Critical care"
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    "resumen" => array:2 [
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Evaluar los factores que influyen en el deterioro de la calidad de vida relacionada con la salud &#40;CVRS&#41; de pacientes traumatizados ingresados en una UCI&#46;</p> <span class="elsevierStyleSectionTitle">Dise&#241;o</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo observacional&#46;</p> <span class="elsevierStyleSectionTitle">&#193;mbito</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">UCI polivalente de un hospital universitario de segundo nivel con servicio de neurocirug&#237;a 24<span class="elsevierStyleHsp" style=""></span>h&#46;</p> <span class="elsevierStyleSectionTitle">Pacientes</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pacientes traumatizados ingresados en la UCI durante un periodo de 2 a&#241;os&#46; Evaluaci&#243;n de CVRS previa&#44; a los 6 y 12 meses del alta&#46;</p> <span class="elsevierStyleSectionTitle">Variables de inter&#233;s</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Se recogen variables demogr&#225;ficas&#44; tipo y gravedad de lesiones &#40;AIS&#41;&#44; nivel de gravedad &#40;APACHE II&#44; ISS&#44; TRISS&#41;&#44; estancia&#44; procedimientos&#44; mortalidad y CVRS seg&#250;n los cuestionarios SF-36 y EQ-5D&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se complet&#243; el seguimiento en 110 pacientes que mostraron un deterioro significativo de su CVRS en todas las dimensiones evaluadas<span class="elsevierStyleItalic">&#46;</span> Seg&#250;n el SF-36 se deterior&#243; m&#225;s el rol f&#237;sico a los 12 meses&#44; aunque el componente mental disminuy&#243; m&#225;s que el componente f&#237;sico a los 6 meses&#46; La EVA del EQ-5D baj&#243; a los 6 meses hasta 55 &#40;19&#41; y aument&#243; a los 12 meses hasta 66 &#40;17&#41;&#46; En el an&#225;lisis de regresi&#243;n log&#237;stica m&#250;ltiple las variables relacionadas con peor CVRS fueron&#58; la edad &#62;<span class="elsevierStyleHsp" style=""></span>45 a&#241;os&#44; un TRISS<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>10&#44; peor calidad de vida previa y tener una lesi&#243;n grave de las extremidades&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Los pacientes muestran un deterioro marcado de su CVRS a los 6 meses con mejor&#237;a a los 12 meses&#44; aunque sin llegar a igualar su estado previo&#46; Los factores que determinan peor calidad de vida son la edad&#44; la gravedad&#44; la CVRS previa y las lesiones graves de las extremidades&#46;</p>"
      ]
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">To evaluate factors influencing the deterioration of health-related quality of life &#40;HRQoL&#41; in trauma patients admitted to an ICU&#46;</p> <span class="elsevierStyleSectionTitle">Design</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">A prospective observational study was carried out&#46;</p> <span class="elsevierStyleSectionTitle">Setting</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">The combined medical&#47;surgical ICU in a university secondary hospital with 24-hour neurosurgery service&#46;</p> <span class="elsevierStyleSectionTitle">Patients</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Trauma patients admitted to the ICU during a two-year period&#46; HRQoL assessment prior to admission to the ICU&#44; and at 6 and 12 months after discharge&#46;</p> <span class="elsevierStyleSectionTitle">Main variables</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Demographic variables&#44; type and severity of injury &#40;AIS&#41;&#44; severity &#40;APACHE II&#44; ISS&#44; TRISS&#41;&#44; length of stay&#44; procedures&#44; mortality and HRQoL according to the SF-36 and EQ-5D&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">We completed the monitoring of 110 patients that showed significant impairment of their HRQoL in all the dimensions assessed&#46; According to the SF-36&#44; physical role was more deteriorated at 12 months&#44; but the mental component decreased more than the physical component after 6 months&#46; The VAS scale of the EQ-5D decreased to 55 at 6 months &#40;19&#41; and increased to 66 at 12 months &#40;17&#41;&#46; In the multiple logistic regression analysis&#44; the variables associated with poorer HRQoL were age &#62; 45 years&#44; TRISS &#62; 10&#44; previous porer quality of life&#44; and serious injuries in the extremities&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Patients showed marked deterioration of their HRQoL at 6 months&#44; followed by overall improvement at 12 months&#44; though without reaching their previous state&#46; The factors that determine poorer quality of life include age&#44; severity&#44; previous HRQoL&#44; and severe injuries in the extremities&#46;</p>"
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        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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          "es" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Diagrama de flujo de los pacientes del grupo de estudio&#46;</p>"
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      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figura 2"
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        "figura" => array:1 [
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          "es" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Puntuaciones medias en cada una de las dimensiones del SF-36&#46; &#40;B&#41; Porcentaje de problemas en cada dimensi&#243;n del EQ-5D&#46; L&#237;nea continua&#58; pre-UCI&#46; L&#237;nea discontinua&#58; 6 meses post- UCI&#46; L&#237;nea gris&#58; 12 meses post-UCI&#46; Significaci&#243;n estad&#237;stica &#40;&#42;&#42;&#41; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#46;</p>"
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      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figura 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1267
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        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Evoluci&#243;n &#40;previa&#44; 6 meses y a los 12 meses&#41; del componente f&#237;sico del SF-36 &#40;A&#41;&#44; componente mental del SF-36 &#40;B&#41; y EVA del EQ-5D &#40;C&#41; &#40;en l&#237;neas de puntos los valores de EVA seleccionados para considerar una mala CVRS&#58; 85 previa y 65 a los 12 meses&#41;&#46;</p>"
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      3 => array:7 [
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        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">APACHE II&#58; Acute Physiology And Chronic Health Evaluation&#59; EVA&#58; escala visual anal&#243;gica&#59; Extrem&#46;&#58; extremidades inferiores y superiores&#59; ISS&#58; Injury Severity Store&#59; NPT&#58; nutrici&#243;n parenteral total&#59; TCE&#58; traumatismo craneoencef&#225;lico&#46; TRISS&#58; Trauma Injury Severity Score&#59; UCI&#58; Unidad de Cuidados Intensivos&#59; VM&#58; ventilaci&#243;n mec&#225;nica&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Noradrenalina&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Scores</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>APACHE II&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10 &#40;7-15&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ISS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">17 &#40;13-25&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">19 &#40;10-25&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>TRISS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#44;2 &#40;1&#44;1-8&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#44;7 &#40;1&#44;8-10&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;935&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Estancia</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>APACHE II&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12 &#40;9-16&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9 &#40;6-12&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ISS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">19 &#40;13-24&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">17 &#40;9-25&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>TRISS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#44;1 &#40;1&#44;2-9&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#44;8 &#40;0&#44;7-5&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>UCI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12 &#40;7-26&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">TRISS<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#44;5 &#40;1&#44;2-11&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">EVA previa &#8804;<span class="elsevierStyleHsp" style=""></span>85&nbsp;\t\t\t\t\t\t\n
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      "titulo" => "Bibliograf&#237;a"
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        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:37 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "M&#46; Segui-Gomez"
                            1 => "E&#46;J&#46; MacKenzie"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Epidemiol Rev"
                        "fecha" => "2003"
                        "volumen" => "25"
                        "paginaInicial" => "3"
                        "paginaFinal" => "19"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12923986"
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                        ]
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                    ]
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            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46; L&#243;pez"
                            1 => "P&#46; Serrano"
                            2 => "B&#46; Duque"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Trauma"
                        "fecha" => "2004"
                        "volumen" => "56"
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            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "A fate worse than death&#63; Long-term outcome of trauma patients admitted to the surgical intensive care unit"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
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                            1 => "T&#46; Tripp"
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                        "tituloSerie" => "J Trauma"
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                        "volumen" => "67"
                        "paginaInicial" => "341"
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            3 => array:3 [
              "identificador" => "bib0020"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "P&#46;A&#46; Cameron"
                            1 => "B&#46;J&#46; Gabbe"
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                  ]
                  "host" => array:1 [
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                      "doi" => "10.1016/j.injury.2006.07.015"
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              "etiqueta" => "5"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "J&#46; Trujillano"
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                            4 => "A&#46; Rodriguez-Pozo"
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                    0 => array:2 [
                      "doi" => "10.1186/1471-2288-9-83"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                            1 => "J&#46;K&#46; Stanghelle"
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                            3 => "K&#46;S&#46; Roaldsen"
                            4 => "J&#46; Pillgram-Larsen"
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                    0 => array:1 [
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                  "contribucion" => array:1 [
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                          "etal" => false
                          "autores" => array:5 [
                            0 => "K&#46; T&#248;ien"
                            1 => "I&#46;S&#46; Bredal"
                            2 => "L&#46; Skogstad"
                            3 => "H&#46; Myhren"
                            4 => "O&#46; Ekeberg"
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                      "doi" => "10.1186/1757-7241-19-22"
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                            1 => "D&#46;M&#46; Vandijck"
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                            3 => "L&#46; Annemans"
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              "etiqueta" => "9"
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                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Minerva Anestesiol"
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                        "volumen" => "72"
                        "paginaInicial" => "479"
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              "etiqueta" => "10"
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                          "etal" => false
                          "autores" => array:6 [
                            0 => "E&#46;F&#46; Van Beeck"
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                            3 => "W&#46;J&#46; Meerding"
                            4 => "S&#46; Mulder"
                            5 => "M&#46;L&#46; Essink-Bot"
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                    0 => array:2 [
                      "doi" => "10.1097/TA.0b013e31802e70c7"
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            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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                        0 => array:2 [
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                            2 => "W&#46; Haddon Jr&#46;"
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                  "host" => array:1 [
                    0 => array:1 [
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                        "tituloSerie" => "J Trauma"
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ORIGINAL
Factores de riesgo de deterioro de calidad de vida en pacientes traumáticos críticos. Valoración a los 6 y 12 meses del alta de la unidad de cuidados intensivos
Risk factors for the deterioration of quality of life in critical trauma patients. Assessment at 6 and 12 months after discharge from the intensive care unit
L. Serviá Goixarta,
Autor para correspondencia
lserviag@gmail.com

Autor para correspondencia.
, M. Badia Castellóa, N. Montserrat Ortiza, G. Bello Rodrigueza, E. Vicario Izquierdoa, J. Vilanova Corsellesa, J. Trujillano Cabelloa,b
a Servicio de Medicina Intensiva, Hospital Universitario Arnau de Vilanova, Lleida, España
b Departamento de Ciencias Médicas Básicas, Universidad de Lleida, IRBLLEIDA, Lleida, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">Las lesiones traum&#225;ticas constituyen un importante problema de salud p&#250;blica en los pa&#237;ses desarrollados&#44; siendo la principal causa de muerte en j&#243;venes menores de 45 a&#241;os y la quinta en el conjunto de todas las edades<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Las lesiones traum&#225;ticas&#44; muy especialmente las derivadas de los accidentes de tr&#225;fico&#44; generan un alto coste econ&#243;mico desde la fase inicial de su asistencia prehospitalaria hasta completarse la fase final de rehabilitaci&#243;n<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">El objetivo principal que se marca un sistema de cuidado traumatol&#243;gico es disminuir la mortalidad pero un objetivo m&#225;s ambicioso es conseguir la reintegraci&#243;n personal&#44; familiar y social&#44; ya que las lesiones generan importantes discapacidades en los pacientes que sobreviven a un traumatismo<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46; Por tanto&#44; se hace imprescindible valorar la repercusi&#243;n de las lesiones traum&#225;ticas sobre la calidad de vida relacionada con la salud &#40;CVRS&#41;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Los pacientes con patolog&#237;a traum&#225;tica presentan unas caracter&#237;sticas diferenciales sobre el resto de los pacientes ingresados en las unidades de cuidados intensivos &#40;UCI&#41;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; Generalmente son personas j&#243;venes&#44; sin comorbilidades asociadas y en los que las lesiones traum&#225;ticas generan importantes deficiencias&#44; discapacidades y minusval&#237;as<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46; Probablemente todos estos conceptos son mucho m&#225;s amplios que la simple interpretaci&#243;n de las variables vivo o muerto para evaluar el resultado final a largo plazo de la asistencia a estos pacientes&#46; El conocimiento de la calidad de vida proporciona informaci&#243;n general sobre la salud f&#237;sica&#44; mental y social&#46; Tambi&#233;n nos informa de c&#243;mo estas discapacidades afectan a aspectos de bienestar&#44; como la percepci&#243;n de un individuo con relaci&#243;n a los objetivos&#44; expectativas en su vida e impacto psicol&#243;gico<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">A pesar del creciente inter&#233;s&#44; no hay muchos estudios realizados espec&#237;ficamente en la poblaci&#243;n traum&#225;tica ingresada en UCI<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a>&#46; The European Consumer Safety Association &#40;ECOSA&#41; cre&#243; un grupo para establecer las gu&#237;as de trabajo para cuantificar el grado de discapacidad y el deterioro en la calidad de vida de los pacientes traum&#225;ticos tras una exhaustiva revisi&#243;n bibliogr&#225;fica entre los a&#241;os 1995-2005&#46; Aunque en estas gu&#237;as publicadas en 2007 se recomendaba como cuestionarios de salud el EQ-5D y en segundo lugar el SF-36&#44; los estudios que se han realizado hasta la fecha han utilizado cuestionarios muy diversos &#40;SIP&#44; QWB&#44; QoL-Bref&#44; NPH&#44; etc&#46;&#41;&#46; Igualmente ECOSA recomend&#243; realizar estudios longitudinales para poder establecer la evoluci&#243;n temporal en las diferentes fases de la recuperaci&#243;n de un traumatismo&#46; Se establece una clasificaci&#243;n temporal con una fase inicial de tratamiento agudo &#40;0-8 semanas&#41;&#44; fase de rehabilitaci&#243;n &#40;1-3 meses&#41;&#44; fase de adaptaci&#243;n &#40;3-6 meses&#41; y finalmente una fase final de estabilidad &#40;6-24 meses&#41;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Los objetivos de nuestro trabajo son conocer la CVRS de los pacientes traum&#225;ticos ingresados en nuestra UCI&#44; tanto previa como en su evoluci&#243;n a los 6 y 12 meses mediante los instrumentos de medida EQ-5D y SF-36 y determinar los factores de riesgo que condicionan una peor CVRS al a&#241;o del alta&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pacientes y m&#233;todo</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pacientes</span><p id="par0035" class="elsevierStylePara elsevierViewall">Estudio prospectivo en una UCI polivalente de un hospital universitario de referencia de 450 camas de segundo nivel siendo centro de referencia provincial para la asistencia del paciente neurocr&#237;tico&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Se analizaron todos los pacientes traumatizados ingresados de forma consecutiva entre el 1 de enero de 2005 y el 31 de diciembre de 2006 en nuestra UCI&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Se incluyeron todos los pacientes supervivientes mayores de 16 a&#241;os y con una estancia en UCI superior a 24<span class="elsevierStyleHsp" style=""></span>h&#46; Se excluyeron los pacientes trasladados a centros de referencia &#40;4 lesionados medulares&#41;&#44; aquellos que presentaban antecedentes psiqui&#225;tricos o un d&#233;ficit cognitivo &#40;previo o adquirido&#41; que imposibilitaba completar el cuestionario de salud y los pacientes de habla extranjera que imped&#237;a una comprensi&#243;n correcta de las preguntas&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">De cada paciente se recogieron datos de edad&#44; sexo y antecedentes de enfermedad cr&#243;nica definida seg&#250;n el APACHE II&#59; asimismo&#44; caracter&#237;sticas del tipo de accidente &#40;tr&#225;fico&#44; laboral y otros&#41; y nivel de gravedad seg&#250;n el ISS<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#44; el TRISS<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> y el APACHE II<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#46; Seg&#250;n regi&#243;n corporal implicada&#44; los pacientes se clasificaron como traumatismo grave&#58; craneoencef&#225;lico &#40;TCE&#41;&#44; tor&#225;cico&#44; abdominal o de extremidades que incluye tanto superiores como inferiores con una puntuaci&#243;n de AIS<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>3<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Se recogieron procedimientos como ventilaci&#243;n mec&#225;nica&#44; necesidad de noradrenalina&#44; utilizaci&#243;n de nutrici&#243;n parenteral&#44; variables cl&#237;nicas de seguimiento como estancia y mortalidad en UCI y hospitalaria&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">El estudio recibi&#243; la aprobaci&#243;n institucional del Comit&#233; &#201;tico de Investigaci&#243;n cl&#237;nica del hospital&#46; Todos los participantes dieron su consentimiento informado para ser incluidos para su seguimiento&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Encuestas de calidad de vida</span><p id="par0065" class="elsevierStylePara elsevierViewall">Utilizamos los cuestionarios gen&#233;ricos de salud EQ-5D y SF-36 en sus versi&#243;n espa&#241;ola&#44; ya validada en nuestro &#225;mbito de intensivos por nuestro grupo en un estudio anterior<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">El cuestionario EQ-5D valora el estado de salud en 5 dimensiones&#58; movilidad&#44; cuidado personal&#44; actividades cotidianas&#44; dolor&#47;malestar y ansiedad&#47;depresi&#243;n con 3 niveles de gravedad en cada dimensi&#243;n&#46; Incluye tambi&#233;n una escala visual anal&#243;gica &#40;EVA&#41; de valoraci&#243;n general y la obtenci&#243;n de un &#237;ndice o tarifa generado por el estado de salud obtenido<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">El SF-36 contiene 36 &#237;tems que se miden en 8 dimensiones &#40;funci&#243;n f&#237;sica&#44; rol f&#237;sico&#44; rol emocional&#44; funci&#243;n social&#44; dolor corporal&#44; salud mental&#44; vitalidad y salud general&#41; obteniendo una puntuaci&#243;n del 0 al 100&#44; de tal manera que a mayor puntuaci&#243;n mejor estado de salud percibida&#46; Tambi&#233;n se calcul&#243; el componente f&#237;sico &#40;CF&#41; y el componente mental &#40;CM&#41; obtenidos a partir de las 8 dimensiones<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Calidad de vida pre y postunidad de cuidados intensivos &#40;6 y 12 meses&#41;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Para evaluar la calidad de vida previa al ingreso en UCI&#44; referida a 4 semanas antes del ingreso en UCI&#44; se realizaron las 2 encuestas &#40;EQ-5D y SF-36&#41; al alta de la UCI o dentro de las primeras 48<span class="elsevierStyleHsp" style=""></span>h de estancia posterior en planta de hospitalizaci&#243;n&#46; Se insist&#237;a en que el paciente cumplimentara los cuestionarios por s&#237; mismo&#59; se permiti&#243; ayuda por un familiar pr&#243;ximo solamente cuando el paciente era incapaz de leer las preguntas o de escribir las respuestas&#46; Las encuestas post-UCI se realizaron a los 6 y 12 meses del alta de la unidad&#46; Se contactaba por tel&#233;fono y los pacientes se citaban para acudir a nuestra consulta&#46; Las encuestas se realizaban bajo la supervisi&#243;n de un m&#233;dico entrenado que ofrec&#237;a las explicaciones previas antes de ser autoadministradas&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Se defini&#243; una mala CVRS previa como la obtenci&#243;n de una EVA inferior al percentil 25 y a los 12 meses cuando el valor de EVA no superaba el percentil 50 de la muestra&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Metodolog&#237;a estad&#237;stica</span><p id="par0090" class="elsevierStylePara elsevierViewall">El an&#225;lisis estad&#237;stico descriptivo incluy&#243; media &#40;desviaci&#243;n est&#225;ndar&#41;&#44; mediana &#40;intervalo intercuartil&#41;&#44; o porcentaje seg&#250;n las caracter&#237;sticas de las variables&#46; Las dimensiones del SF-36 se expresan como media &#40;desviaci&#243;n est&#225;ndar&#41;&#44; y las del EQ-5D como porcentaje de problemas&#46; Para la comparaci&#243;n de los datos cl&#237;nicos y demogr&#225;ficos del grupo de estudio se utiliz&#243; el test estad&#237;stico de &#967;<span class="elsevierStyleSup">2</span> para variables categ&#243;ricas&#44; y para las variables continuas el test no param&#233;trico de Kruskal-Wallis &#40;variables no relacionadas&#41; o el test de Friedman &#40;variables relacionadas&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Se realiz&#243; un an&#225;lisis de factores de riesgo de mala CVRS a los 12 meses calculando las odds ratio &#40;OR&#41; &#40;y sus intervalos de confianza al 95&#37;&#41; de forma univariante y mediante un modelo multivariante &#40;regresi&#243;n log&#237;stica m&#250;ltiple con selecci&#243;n autom&#225;tica de variables por pasos&#41; incorporando en el modelo inicial aquellos factores significativos univariantes&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">El nivel de significaci&#243;n estad&#237;stica aceptado fue del 5&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; Se emple&#243; el paquete estad&#237;stico SPSS &#40;versi&#243;n 15&#46;0&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Resultados</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pacientes</span><p id="par0105" class="elsevierStylePara elsevierViewall">Durante el periodo de estudio ingresaron 213 pacientes de causa traum&#225;tica en la UCI &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; El mes previo al inicio del estudio se realiz&#243; una prueba piloto con 10 pacientes que cumplimentaron las 2 encuestas &#40;EQ-5D y SF-36&#41; pero no se incluyeron finalmente en el estudio&#46; La mortalidad de los pacientes traum&#225;ticos fue del 21&#37; &#40;45 pacientes&#41;&#46; Se excluyeron 38 pacientes &#40;12 por problemas de idioma y 26 por deterioro cognitivo secundario a TCE&#41;&#46; El grupo potencial de respuesta fueron 130 pacientes y respondieron 110 pacientes &#40;porcentaje de respuesta del 84&#37;&#41;&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se muestran las caracter&#237;sticas demogr&#225;ficas del grupo de estudio&#46; Los pacientes traum&#225;ticos presentaron una edad media de 41&#44;7 a&#241;os&#44; siendo significativamente m&#225;s j&#243;venes los pacientes del grupo excluidos&#44; hubo un predominio de varones &#40;75&#44;6&#37;&#41; y el accidente de tr&#225;fico fue la causa m&#225;s frecuente del traumatismo con el TCE y el de t&#243;rax como las 2 &#225;reas anat&#243;micas m&#225;s afectadas&#46; El nivel de gravedad seg&#250;n el APACHE II fue 10 &#40;7-15&#41; con un ISS de 17 &#40;10-25&#41; y estancia en UCI de 8 &#40;4-21&#41; d&#237;as sin detectar diferencias entre los tres grupos&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Evoluci&#243;n en la calidad de vida &#40;previa&#44; 6 y 12 meses&#41;</span><p id="par0110" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a> se muestran las puntuaciones de las 8 dimensiones del SF-36 &#40;previa al ingreso en UCI&#44; 6 y 12 meses&#41; y en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a> los porcentajes de problemas seg&#250;n dimensi&#243;n del EQ-5D &#40;con EVA y tarifa&#41;&#46; Se compararon seg&#250;n sexo&#44; edad y zona anat&#243;mica afectada&#46; Las mujeres presentaron peores valores tanto previos como en el seguimiento a los 6 y 12 meses del traumatismo&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">La calidad de vida mostr&#243; un deterioro general en todas las dimensiones de ambos cuestionarios como se observa en las <a class="elsevierStyleCrossRef" href="#fig0010">figura 2</a>A y 2B&#46; Se aprecia una mayor repercusi&#243;n en las dimensiones f&#237;sicas&#46; En la <a class="elsevierStyleCrossRef" href="#fig0015">figura 3</a> se observa la evoluci&#243;n de los componentes f&#237;sico y metal del SF-36 &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>A y B&#41; y EVA del EQ-5D &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>C&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">El CF y CM sufrieron un descenso significativo al a&#241;o del alta de UCI&#46; Aunque el deterioro a los 6 meses fue mayor para el CM&#44; su recuperaci&#243;n al a&#241;o del alta fue mejor que en el CF pero sin llegar a conseguir los valores previos al accidente&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Factores de riesgo de mala calidad de vida a los 12 meses</span><p id="par0125" class="elsevierStylePara elsevierViewall">El punto de corte de EVA a los 12 meses que defini&#243; la existencia de una mala CVRS fue de 65&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a> se muestran las diferencias entre los grupos seg&#250;n este punto de corte&#46; Los pacientes con peor CVRS fueron m&#225;s mayores&#44; con mayor porcentaje de mujeres&#44; mayor nivel de gravedad y mayor estancia en UCI y hospitalaria&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">Inicialmente para determinar los factores relacionados con una peor CVRS a los 12 meses &#40;definida como EVA menor de 65&#41; se realiz&#243; un an&#225;lisis de regresi&#243;n log&#237;stica univariante obteniendo como variables predictoras&#58; edad superior a 45 a&#241;os 3&#44;2&#40;1&#44;4-1&#44;7&#41;&#44; mujer 3&#44;1&#40;1&#44;2-7&#44;6&#41;&#44; nutrici&#243;n parenteral total 3&#44;8 &#40;1&#44;6-9&#44;1&#41;&#44; APACHE II<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>15 3&#44;3 &#40;1&#44;1-10&#44;8&#41;&#44; ISS<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>25 2&#44;5 &#40;1&#44;1-14&#44;8&#41;&#44; TRISS<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>10 2&#44;9 &#40;1&#44;2-7&#44;4&#41;&#44; estancia &#8805; 7 3&#44;9 &#40;1&#44;7-8&#44;9&#41;&#44; EVA previa &#8804;<span class="elsevierStyleHsp" style=""></span>3&#44;5 &#40;1&#44;4-9&#44;0&#41; y extremidades &#8805;<span class="elsevierStyleHsp" style=""></span>3 2&#44;7 &#40;1&#44;2-7&#44;2&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">En el an&#225;lisis multivariable las variables que obtuvieron significaci&#243;n estad&#237;stica fueron un TRISS mayor de 10&#44; tener una EVA previa menor o igual a 85 &#40;percentil 25 de la muestra&#41; y tener una afectaci&#243;n grave de extremidades &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discusi&#243;n</span><p id="par0140" class="elsevierStylePara elsevierViewall">Nuestros resultados muestran que los pacientes que logran superar el ingreso en UCI evidencian un deterioro de su calidad de vida en todas las dimensiones evaluadas a los 6 meses&#44; con una mejor&#237;a a los 12 meses&#44; aunque sin llegar a igualar su estado previo valorado en ambos cuestionarios&#46; Los pacientes presentan un descenso de las funciones f&#237;sicas y sociales&#44; un incremento del dolor corporal&#44; menor vitalidad y un descenso del estado de salud general y mental&#46; Seg&#250;n el cuestionario SF- 36&#44; la dimensi&#243;n que m&#225;s se deteriora en el paciente con un traumatismo grave al a&#241;o es el rol f&#237;sico aunque el conjunto del componente mental disminuye m&#225;s&#44; en los primeros 6 meses&#44; que el componente f&#237;sico&#46; Debemos recordar que el grupo de pacientes traum&#225;ticos que sobreviven a un ingreso en UCI est&#225; constituido principalmente por pacientes j&#243;venes que presentaban una CVRS previa excelente<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Otros estudios publicados han comprobado que de los pacientes ingresados en UCI&#44; el subgrupo de pacientes traum&#225;ticos son los que sufren un mayor deterioro de su CVRS<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;20</span></a>&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">El estudio multivariante muestra que los factores que influyen en una peor CVRS son la edad&#44; la calidad de vida previa&#44; la gravedad al ingreso y las lesiones graves de las extremidades&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">En la mayor&#237;a de los estudios&#44; la edad se muestra como un factor determinante en el empeoramiento de la calidad de vida y tienen una peor recuperaci&#243;n en la evoluci&#243;n posterior a los 12 meses<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;21</span></a>&#46; En el estudio de V&#225;zquez Mata et al&#46; la edad se mostr&#243; como el factor que m&#225;s influy&#243; en una peor calidad de vida<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46; A medida que aumenta la edad&#44; el deterioro es mayor y de forma m&#225;s acusada en aquellas dimensiones que valoran la capacidad f&#237;sica<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;23</span></a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Destacar en el an&#225;lisis multivariable que las mujeres no presentan peores valores de su calidad de vida en todas las dimensiones respecto a los hombres aunque existe una tendencia<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;24</span></a>&#46; En la mayor&#237;a de los trabajos s&#237; que se obtienen estas diferencias seg&#250;n el g&#233;nero<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">En el an&#225;lisis multivariante&#44; al igual que en el estudio de Vazquez Mata et al&#46;&#44; la CVRS previa al accidente se muestra como un factor determinante de un mayor deterioro de CVRS al a&#241;o del accidente<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">M&#225;s controvertida es la relaci&#243;n de la gravedad del traumatismo con el deterioro en la CVRS&#46; Aunque los scores de gravedad se dise&#241;aron como &#237;ndices predictores de mortalidad&#44; algunos autores han observado una buena correlaci&#243;n en el deterioro de la CVRS&#44; tanto en los scores generales &#40;APACHE II y SAPS II&#41; como en scores espec&#237;ficos &#40;ISS&#41;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;25&#8211;28</span></a>&#46; Por el contrario&#44; otros estudios no logran demostrar que una mayor gravedad al ingreso tenga que relacionarse con un mayor deterioro de su CVRS<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;29&#8211;31</span></a>&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Destacar que en UCI ingresan pacientes con diferentes niveles de gravedad y en ocasiones el objetivo es la vigilancia de lesiones que potencialmente pueden amenazar la vida del paciente &#40;traumatismos tor&#225;cicos o de v&#237;scera maciza&#44; etc&#46;&#41;&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">En un estudio sobre 507 pacientes que hab&#237;an sufrido un accidente de tr&#225;fico con un 76&#37; de lesiones menores&#44; el 26&#37; de los pacientes padec&#237;an s&#237;ntomas psicol&#243;gicos y un 21&#37; ten&#237;an dolores moderados o severos tras 3 a&#241;os de seguimiento<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a>&#46; Seg&#250;n Brasel et al&#46; parece existir una fuerte correlaci&#243;n entre la gravedad de las lesiones seg&#250;n el ISS y la afectaci&#243;n de las dimensiones f&#237;sicas en la fase inicial postraumatismo pero no se relaciona con deterioro de las dimensiones mentales tanto al inicio como en el seguimiento posterior a los 6 meses<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&#46; Nuestro estudio encuentra que los pacientes m&#225;s graves &#40;medidos con la escala TRISS&#41; tienen peor CVRS al a&#241;o del alta de UCI&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Algunos estudios han demostrado la influencia del &#225;rea anat&#243;mica afectada en la CVRS posterior&#46; En el trabajo de Holtslag et al&#46; se realiza un seguimiento entre 12-18 meses de 335 pacientes con un ISS<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>15&#44; demostrando que las &#225;reas anat&#243;micas que influyen de forma independiente en la recuperaci&#243;n posterior son los TCE&#44; la lesiones de la columna vertebral y las lesiones de las extremidades inferiores<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&#46; En nuestro trabajo coincidimos en que las lesiones m&#225;s graves de las extremidades se asocian con una peor recuperaci&#243;n tanto a los 6 como a los 12 meses&#44; aunque no podemos evaluar a los pacientes con lesiones medulares al ser trasladados a centros de referencia<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;28</span></a>&#46; Adem&#225;s esta recuperaci&#243;n suele ser m&#225;s lenta que la observada en lesiones de otras &#225;reas anat&#243;micas<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;31</span></a>&#46; Este es un factor que se debe tener en cuenta para poder programar las diferentes fases de rehabilitaci&#243;n del paciente con un mismo nivel de gravedad seg&#250;n el &#225;rea lesionada y si existe lesi&#243;n grave de las extremidades&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Existe controversia sobre si el TCE es un factor determinante en el deterioro de la calidad de vida&#46; Aunque varios estudios han establecido el TCE como un factor independiente en el deterioro de la calidad de vida<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;33</span></a> otros estudios no hallan esta relaci&#243;n<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;25</span></a>&#46; En nuestro modelo&#44; la presencia de un TCE severo no se comporta como una variable independiente&#46; Varias causas pueden justificar estos resultados&#46; Los TCE con alteraciones cognitivas son motivo de exclusi&#243;n del trabajo y coincidimos con las recomendaciones de Mackenzie de que en los pacientes con traumatismo craneal debe a&#241;adirse al cuestionario general una evaluaci&#243;n de la funci&#243;n cognitiva<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>&#46; Si un paciente tiene un deterioro de la funci&#243;n cognitiva puede tener alterada la percepci&#243;n del deterioro funcional e incluso en algunos casos la percepci&#243;n es que mejora respecto a la calidad de vida previa&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Aunque las lesiones abdominales y tor&#225;cicas son una de las principales causa de muerte en la fase inicial de la asistencia al traumatismo grave&#44; los resultados a largo plazo son buenos sin deteriorarse la CVRS<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a>&#46; Por otro lado&#44; Kiely et al&#46; con una poblaci&#243;n de pacientes traum&#225;ticos &#40;ISS<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>9&#41; observan que las 2 &#225;reas que m&#225;s deterioran la calidad de vida al mes del traumatismo son las extremidades y el t&#243;rax&#59; por el contrario&#44; a los 6 meses el TCE es el que determina una peor evoluci&#243;n<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a>&#46; Todo ello dificulta que se llegue a un consenso sobre el tiempo id&#243;neo de seguimiento<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;29&#44;36</span></a>&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Otros factores como las complicaciones adquiridas durante su ingreso y la estancia hospitalaria se han relacionado con el resultado final<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;21&#44;29</span></a>&#46; En nuestro caso coincidimos con otros estudios en que los d&#237;as de estancia no se asocian con el deterioro de la calidad de vida<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;37</span></a>&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Nuestro estudio tiene varias limitaciones&#46; El trabajo fue realizado en una sola UCI&#44; con las caracter&#237;sticas espec&#237;ficas de nuestro hospital&#46; En nuestro centro los pacientes que presentan lesiones de la columna vertebral son trasladados a un centro de referencia y no han podido ser evaluados&#46; Ser&#237;an deseables estudios multic&#233;ntricos y con un mayor n&#250;mero de pacientes&#46; La exclusi&#243;n de los pacientes con deterioro cognitivo adquirido no permite evaluar en toda su magnitud a los pacientes con TCE ni tampoco se ha realizado ninguna evaluaci&#243;n espec&#237;fica del deterioro cognitivo&#46; El periodo de seguimiento de un a&#241;o podr&#237;a ser insuficiente para valorar la recuperaci&#243;n en todas las dimensiones&#44; aunque no existen recomendaciones claras a este respecto&#59; valoraciones m&#225;s all&#225; de 18-24 meses no est&#225;n suficientemente validadas&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">En resumen&#44; los pacientes ingresados en las UCI sufren un marcado deterioro de su CVRS&#46; Se deben seguir haciendo estudios longitudinales que eval&#250;en la evoluci&#243;n de la calidad de vida de los pacientes traum&#225;ticos supervivientes de un ingreso en UCI y obtener una visi&#243;n global del problema&#46; Se deben realizar m&#225;s estudios que determinen los tiempos de seguimiento en funci&#243;n de las &#225;reas anat&#243;micas afectadas y del paciente politraumatizado en general ingresado en la UCI&#46; Debe analizarse el grado de deterioro cognitivo tras sufrir un TCE y c&#243;mo este influye en un posible deterioro de la CVRS&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">La detecci&#243;n de factores que permitan predecir qu&#233; pacientes van a presentar una peor calidad de vida &#40;edad&#44; gravedad&#44; CVRS previa y lesiones graves de las extremidades&#41; puede ser de utilidad para un abordaje asistencial adaptado a las necesidades de cada situaci&#243;n cl&#237;nica&#44; logrando unos cuidados sanitarios de calidad y mejorando el pron&#243;stico de estos pacientes&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicto de intereses</span><p id="par0220" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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            2 => "Dise&#241;o"
            3 => "&#193;mbito"
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            0 => "Abstract"
            1 => "Objective"
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              "titulo" => "Calidad de vida pre y postunidad de cuidados intensivos &#40;6 y 12 meses&#41;"
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              "titulo" => "Metodolog&#237;a estad&#237;stica"
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            1 => array:2 [
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              "titulo" => "Factores de riesgo de mala calidad de vida a los 12 meses"
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          "titulo" => "Discusi&#243;n"
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          "titulo" => "Bibliograf&#237;a"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2012-05-23"
    "fechaAceptado" => "2012-10-20"
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          "palabras" => array:5 [
            0 => "Calidad de vida relacionada con la salud"
            1 => "Short Form SF-36"
            2 => "EuroQoL 5D"
            3 => "Politraumatizado"
            4 => "Cuidados intensivos"
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            0 => "Health-related quality of life"
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            2 => "EuroQoL 5D"
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    "resumen" => array:2 [
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Evaluar los factores que influyen en el deterioro de la calidad de vida relacionada con la salud &#40;CVRS&#41; de pacientes traumatizados ingresados en una UCI&#46;</p> <span class="elsevierStyleSectionTitle">Dise&#241;o</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo observacional&#46;</p> <span class="elsevierStyleSectionTitle">&#193;mbito</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">UCI polivalente de un hospital universitario de segundo nivel con servicio de neurocirug&#237;a 24<span class="elsevierStyleHsp" style=""></span>h&#46;</p> <span class="elsevierStyleSectionTitle">Pacientes</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pacientes traumatizados ingresados en la UCI durante un periodo de 2 a&#241;os&#46; Evaluaci&#243;n de CVRS previa&#44; a los 6 y 12 meses del alta&#46;</p> <span class="elsevierStyleSectionTitle">Variables de inter&#233;s</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Se recogen variables demogr&#225;ficas&#44; tipo y gravedad de lesiones &#40;AIS&#41;&#44; nivel de gravedad &#40;APACHE II&#44; ISS&#44; TRISS&#41;&#44; estancia&#44; procedimientos&#44; mortalidad y CVRS seg&#250;n los cuestionarios SF-36 y EQ-5D&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se complet&#243; el seguimiento en 110 pacientes que mostraron un deterioro significativo de su CVRS en todas las dimensiones evaluadas<span class="elsevierStyleItalic">&#46;</span> Seg&#250;n el SF-36 se deterior&#243; m&#225;s el rol f&#237;sico a los 12 meses&#44; aunque el componente mental disminuy&#243; m&#225;s que el componente f&#237;sico a los 6 meses&#46; La EVA del EQ-5D baj&#243; a los 6 meses hasta 55 &#40;19&#41; y aument&#243; a los 12 meses hasta 66 &#40;17&#41;&#46; En el an&#225;lisis de regresi&#243;n log&#237;stica m&#250;ltiple las variables relacionadas con peor CVRS fueron&#58; la edad &#62;<span class="elsevierStyleHsp" style=""></span>45 a&#241;os&#44; un TRISS<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>10&#44; peor calidad de vida previa y tener una lesi&#243;n grave de las extremidades&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Los pacientes muestran un deterioro marcado de su CVRS a los 6 meses con mejor&#237;a a los 12 meses&#44; aunque sin llegar a igualar su estado previo&#46; Los factores que determinan peor calidad de vida son la edad&#44; la gravedad&#44; la CVRS previa y las lesiones graves de las extremidades&#46;</p>"
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">To evaluate factors influencing the deterioration of health-related quality of life &#40;HRQoL&#41; in trauma patients admitted to an ICU&#46;</p> <span class="elsevierStyleSectionTitle">Design</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">A prospective observational study was carried out&#46;</p> <span class="elsevierStyleSectionTitle">Setting</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">The combined medical&#47;surgical ICU in a university secondary hospital with 24-hour neurosurgery service&#46;</p> <span class="elsevierStyleSectionTitle">Patients</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Trauma patients admitted to the ICU during a two-year period&#46; HRQoL assessment prior to admission to the ICU&#44; and at 6 and 12 months after discharge&#46;</p> <span class="elsevierStyleSectionTitle">Main variables</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Demographic variables&#44; type and severity of injury &#40;AIS&#41;&#44; severity &#40;APACHE II&#44; ISS&#44; TRISS&#41;&#44; length of stay&#44; procedures&#44; mortality and HRQoL according to the SF-36 and EQ-5D&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">We completed the monitoring of 110 patients that showed significant impairment of their HRQoL in all the dimensions assessed&#46; According to the SF-36&#44; physical role was more deteriorated at 12 months&#44; but the mental component decreased more than the physical component after 6 months&#46; The VAS scale of the EQ-5D decreased to 55 at 6 months &#40;19&#41; and increased to 66 at 12 months &#40;17&#41;&#46; In the multiple logistic regression analysis&#44; the variables associated with poorer HRQoL were age &#62; 45 years&#44; TRISS &#62; 10&#44; previous porer quality of life&#44; and serious injuries in the extremities&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Patients showed marked deterioration of their HRQoL at 6 months&#44; followed by overall improvement at 12 months&#44; though without reaching their previous state&#46; The factors that determine poorer quality of life include age&#44; severity&#44; previous HRQoL&#44; and severe injuries in the extremities&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">No responden &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Excluidos &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>38&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">p<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Edad &#40;a&#241;os&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&#44;4 &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&#44;5 &#40;18&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44&#44;8 &#40;16&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">33&#44;5 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#44;004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Sexo&#44; var&#243;n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">75&#44;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">75&#44;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">81&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#44;376&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Tipo &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#44;959&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tr&#225;fico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">69&#44;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">68&#44;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">70&#44;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">71&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Laboral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">14&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">15&#44;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">15&#44;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">10&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Otros&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">16&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Tipo &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>TCE<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">47&#44;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">43&#44;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">55&#44;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">52&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;473&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>T&#243;rax<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">45&#44;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">50&#44;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">35&#44;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">36&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Abdomen &#8805;<span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">10&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">10&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">5&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Extrem&#46; &#8805;<span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#44;925&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Procedimientos &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>VM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">57&#44;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>VM&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>NPT&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>APACHE II&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">12 &#40;9-16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">9 &#40;6-12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#44;021&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ISS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">19 &#40;13-24&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">17 &#40;9-25&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>TRISS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Estancia</span><a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>UCI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">12 &#40;7-26&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hospital&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;014&nbsp;\t\t\t\t\t\t\n
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                  """
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                0 => "xTab445115.png"
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            0 => array:3 [
              "identificador" => "tblfn0025"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara">Media &#40;desviaci&#243;n Est&#225;ndar&#41;&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0030"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara">Mediana &#40;rango intercuartil&#41;&#46;</p>"
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            2 => array:3 [
              "identificador" => "tblfn0035"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara">Comparaci&#243;n entre EVA a los 12 meses mayor o menor a 65 con p determinada por test de &#967;<span class="elsevierStyleSup">2</span> para comparaci&#243;n de proporciones o test de Kruskal-Wallis para la comparaci&#243;n de medianas&#46;</p>"
            ]
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          "es" => "<p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas demogr&#225;ficas seg&#250;n EVA &#40;a los 12 meses&#41; mayor o menor de 65 puntos</p>"
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        "identificador" => "tbl0025"
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          "leyenda" => "<p id="spar0150" class="elsevierStyleSimplePara elsevierViewall">EVA&#58; escala visual anal&#243;gica &#40;puntuaci&#243;n EVA a los 12 meses&#41;&#59; Extrem&#46;&#58; extremidades inferiores y superiores&#59; IC&#58; intervalo de confianza al 95&#37;&#59; OR&#58; odds ratio&#59; TRISS&#58; Trauma Injury Severity Score&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;8 &#40;1&#44;2-6&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TRISS<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;5 &#40;1&#44;2-11&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">EVA previa &#8804;<span class="elsevierStyleHsp" style=""></span>85&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;2 &#40;1&#44;4-12&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Extrem&#46; &#8805;<span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">5&#44;2 &#40;1&#44;7-16&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                0 => "xTab445114.png"
              ]
            ]
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        ]
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          "es" => "<p id="spar0145" class="elsevierStyleSimplePara elsevierViewall">Resultados de la regresi&#243;n log&#237;stica multivariante &#40;variable resultado EVA<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>65 puntos&#41;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "Bibliograf&#237;a"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:37 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Measuring the public health impact of injuries"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "M&#46; Segui-Gomez"
                            1 => "E&#46;J&#46; MacKenzie"
                          ]
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Epidemiol Rev"
                        "fecha" => "2003"
                        "volumen" => "25"
                        "paginaInicial" => "3"
                        "paginaFinal" => "19"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12923986"
                            "web" => "Medline"
                          ]
                        ]
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            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
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ISSN: 02105691
Idioma original: Español
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2022 Abril 190 48 238
2022 Marzo 171 54 225
2022 Febrero 196 41 237
2022 Enero 172 46 218
2021 Diciembre 197 44 241
2021 Noviembre 304 60 364
2021 Octubre 235 90 325
2021 Septiembre 149 49 198
2021 Agosto 171 59 230
2021 Julio 137 41 178
2021 Junio 172 35 207
2021 Mayo 237 61 298
2021 Abril 338 89 427
2021 Marzo 200 41 241
2021 Febrero 185 43 228
2021 Enero 130 24 154
2020 Diciembre 118 38 156
2020 Noviembre 150 24 174
2020 Octubre 94 62 156
2020 Septiembre 86 36 122
2020 Agosto 66 35 101
2020 Julio 56 47 103
2020 Junio 65 37 102
2020 Mayo 89 43 132
2020 Abril 111 34 145
2020 Marzo 75 23 98
2020 Febrero 121 57 178
2020 Enero 62 39 101
2019 Diciembre 65 43 108
2019 Noviembre 214 58 272
2019 Octubre 66 24 90
2019 Septiembre 88 46 134
2019 Agosto 55 39 94
2019 Julio 64 33 97
2019 Junio 50 24 74
2019 Mayo 77 65 142
2019 Abril 53 31 84
2019 Marzo 37 41 78
2019 Febrero 46 47 93
2019 Enero 42 40 82
2018 Diciembre 69 68 137
2018 Noviembre 154 103 257
2018 Octubre 118 28 146
2018 Septiembre 27 10 37
2018 Agosto 25 5 30
2018 Julio 32 10 42
2018 Junio 34 7 41
2018 Mayo 20 8 28
2018 Abril 27 12 39
2018 Marzo 30 4 34
2018 Febrero 23 6 29
2018 Enero 44 23 67
2017 Diciembre 28 8 36
2017 Noviembre 42 8 50
2017 Octubre 33 6 39
2017 Septiembre 36 7 43
2017 Agosto 31 14 45
2017 Julio 47 11 58
2017 Junio 53 8 61
2017 Mayo 45 7 52
2017 Abril 36 8 44
2017 Marzo 31 8 39
2017 Febrero 37 7 44
2017 Enero 43 8 51
2016 Diciembre 49 14 63
2016 Noviembre 83 15 98
2016 Octubre 87 24 111
2016 Septiembre 74 21 95
2016 Agosto 59 20 79
2016 Julio 21 23 44
2015 Diciembre 2 0 2
2015 Febrero 1 0 1
2014 Agosto 1 0 1
2014 Junio 2 0 2
2014 Mayo 1 0 1
2014 Marzo 22 0 22
2014 Febrero 33 0 33
2014 Enero 3 0 3
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