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However&#44; StO<span class="elsevierStyleInf">2</span> is defined as a quantification of the OxyHb&#47;HbT ratio in microcirculation of skeletal muscle as an absolute number&#46; On the other hand&#44; skeletal rSO<span class="elsevierStyleInf">2</span> is an index of OxyHb present within a volume of tissue&#59; this index is expressed as the percentage of oxygenated haemoglobin relative to total haemoglobin &#40;HbO<span class="elsevierStyleInf">2</span>&#47;Hb sum&#41;&#46; The INVOS 510 devices employ reflectance mode probes that have one 1&#46;5<span class="elsevierStyleHsp" style=""></span>mm optical fibre to illuminate the tissue and two optical fibres &#40;30<span class="elsevierStyleHsp" style=""></span>mm and 40<span class="elsevierStyleHsp" style=""></span>mm&#41; to detect the backscattered light from the tissue&#46; The 40<span class="elsevierStyleHsp" style=""></span>mm separated fibre measures a greater and deeper tissue volume than the 30<span class="elsevierStyleHsp" style=""></span>mm separated fibre&#46; The difference between the spectral absorbance measured with these two probing depths is used to calculate rSO<span class="elsevierStyleInf">2</span>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Nevertheless&#44; this technique has some difficulties&#44; mainly due to the lack of signal processing and acquisition procedures standardization&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> The first problem arises from the difficulty of establishing a relationship between the two variables and comparing data obtained with different devices&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Moreover&#44; there is no standard application site for measurements&#46; Therefore&#44; using different muscles may derive different values of the variables&#46; These differences might be related&#44; to the local perfusion characteristics &#40;including its response to different stimulus&#41;&#44; the different metabolic functions and states&#44; and the morphological characteristics of each muscle&#44; among others&#46; In this regard&#44; Bezemer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> reported that forearm StO<span class="elsevierStyleInf">2</span> is a more sensitive parameter to haemodynamic changes than thenar StO<span class="elsevierStyleInf">2</span> and that the depth at which StO<span class="elsevierStyleInf">2</span> is measured is of minor influence&#46; On the other hand&#44; Ikossi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> found no association between StO<span class="elsevierStyleInf">2</span> and tissue oxygen pressure &#40;measured directly with electrodes&#41; in deltoid muscle&#46; Recently&#44; our group reported that a brachioradialis rSO<span class="elsevierStyleInf">2</span> greater than 60&#37; at ICU admission was associated with better outcome in septic patients&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The skeletal rSO<span class="elsevierStyleInf">2</span> seems to be an adequate variable for evaluating the microvascular status in patients with severe sepsis&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> However&#44; the site of application is important because there may be differences in the sensitivity of underlying muscle groups and other anatomical structures&#44; to cardiovascular challenges&#46; Unfortunately&#44; there are no studies that have determined rSO<span class="elsevierStyleInf">2</span> in different application sites simultaneously using INVOS 5100 spectroscopy technology&#46; We believe that contributing to clarifying these differences may be helpful in the management of critically ill patients&#44; particularly in those where it is crucial to try to maintain the balance between oxygen supply and demand&#46; The aim of this study was to investigate rSO<span class="elsevierStyleInf">2</span> behaviour in two different brachial muscles in septic patients&#44; a proximal one &#40;deltoid muscle&#44; D&#41; and a distal one &#40;brachioradialis muscle&#44; BR&#41;&#46; The measurements were obtained initially at ICU admission and again 24<span class="elsevierStyleHsp" style=""></span>h after starting the treatment&#46; The specific objectives of the study were&#58; &#40;1&#41; To compare rSO<span class="elsevierStyleInf">2</span> values obtained during the evolution of the patient and simultaneously in both muscles and &#40;2&#41; to determine the association between those values and ICU mortality&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Materials and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">A prospective and observational study was conducted in a 30-bed medical&#8211;surgical ICU in a tertiary university hospital&#46; The investigation was conducted according to the principles outlined in the Declaration of Helsinki&#46; The study protocol was approved by the Joan XXIII University Hospital Ethics Committee &#40;MICRO2 20&#47;2010&#41; and informed consent was given by each patient or their next of kin&#46; Data obtained from rSO<span class="elsevierStyleInf">2</span> were not known by the care team and did not influence any decision about treatment or management&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Patients</span><p id="par0030" class="elsevierStylePara elsevierViewall">Since patients with sepsis are heterogeneous&#44; this study included only those with severe sepsis due to community-acquired pneumonia &#40;CAP&#41;&#46; Inclusion criteria were&#58; &#40;1&#41; severe CAP&#59; &#40;2&#41; age &#62;18 years&#59; &#40;3&#41; less than 6<span class="elsevierStyleHsp" style=""></span>h between ICU admission and the first measurement&#59; and &#40;4&#41; informed consent obtained from patients or relatives&#46; Patients with morbid obesity &#40;Corporal Mass Index &#62;30<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41; were excluded&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Severe CAP was defined as an acute lower tract infection characterized by&#58; &#40;1&#41; an acute pulmonary infiltrate evident on chest radiographs and compatible with pneumonia&#44; &#40;2&#41; confirmatory findings of clinical examination&#44; &#40;3&#41; acquisition of the infection outside a hospital&#44; long-term care facility or nursing home<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#44; and &#40;4&#41; ICU admission&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Procedures</span><p id="par0040" class="elsevierStylePara elsevierViewall">Once the patient has been enrolled&#44; demographic variables were registered and severity of illness was assessed using Acute Physiology and Chronic Health Evaluation II &#40;APACHE II&#41;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#59; Sequential Organ Failure Assessment score &#40;SOFA&#41;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and Simplified Acute Physiology Score 3 &#40;SAPS 3&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The rSO<span class="elsevierStyleInf">2</span> measurements were taken by NIRS using system INVOS 5100 &#40;Somanetics Corporation&#44; Troy&#44; MI&#44; USA&#41;&#44; by the technique previously described&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Briefly&#44; NIRS is a non-invasive technique that uses the differential absorption properties of oxygenated and deoxygenated haemoglobin to evaluate tissue oxygenation&#46; The near-infrared light easily crosses biological tissues&#44; which have a low absorption power&#44; and is absorbed only by haemoglobin&#44; myoglobin and oxidized cytochrome&#44; although the contribution of these latter two to the light attenuation signal is very small&#46; The NIRS INVOS system signal is limited to vessels that have less than 1<span class="elsevierStyleHsp" style=""></span>mm &#40;arterioles&#44; capillary and venules&#41;&#44; since the elevated blood concentration of vessels with greater diameter &#40;and greater light absorption&#41; makes the reflection less probable&#46; The NIRS INVOS technique uses reflectance mode probes that have one 1&#46;5-mm optical fibre to illuminate the tissue to a depth of 4<span class="elsevierStyleHsp" style=""></span>cm&#44; and two optical fibres to detect the backscattered light from the tissue&#46; The signal is then transformed to a digital absolute number &#40;rSO<span class="elsevierStyleInf">2</span>&#41; and carried to a display unit where the values and trends are displayed on the screen&#46; The system updates the rSO<span class="elsevierStyleInf">2</span> value at 10<span class="elsevierStyleHsp" style=""></span>s intervals&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In all patients&#44; two probes were placed on the brachioradialis muscle&#44; located on the anterior outside of the forearm&#44; 1&#8211;2<span class="elsevierStyleHsp" style=""></span>cm below its insertion on the external tip of the radius in both limbs&#44; according to the technique describe by Bezemer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> At the same time&#44; another two probes were placed on the deltoid muscle in both limbs&#44; 1&#8211;2<span class="elsevierStyleHsp" style=""></span>cm below the acromioclavicular joint&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> After a stabilization period of 30&#8211;40<span class="elsevierStyleHsp" style=""></span>s&#44; values for rSO<span class="elsevierStyleInf">2</span> were registered for each of the studied muscles&#46; Measurements were recorded at baseline &#40;ICU admission&#41; and 24<span class="elsevierStyleHsp" style=""></span>h after initiating treatment&#46; No vascular occlusion test was carried out in this study &#40;see &#8216;Discussion&#8217; section&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Statistical analysis</span><p id="par0055" class="elsevierStylePara elsevierViewall">Differences between groups were assessed using chi-square or Fisher&#39;s exact test for discrete variables and the Wilcoxon test and analysis of variance &#40;ANOVA&#41;&#46; The precision of the measurements obtained in both muscle groups was studied through the determination of the coefficient of variation &#40;CV&#41;&#46; Pearson&#39;s correlation coefficient was used to assess the association between continuous variables&#46; The consistency of the values obtained in different application sites was assessed using the intraclass correlation coefficient &#40;ICC&#41;&#44; based on the model of analysis of variance for repeated measures by the process reliability&#46; The strength of the consistency was assessed according to the value of the ICC as&#44; very good &#40;&#62;0&#46;90&#41;&#44; good &#40;0&#46;71&#8211;0&#46;90&#41;&#44; moderate &#40;0&#46;51&#8211;0&#46;70&#41;&#44; mediocre &#40;0&#46;31&#8211;0&#46;50&#41; and null &#40;&#60;0&#46;30&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> In addition&#44; Bland&#8211;Altman analysis was performed&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The predictive value of the variables for mortality was calculated using the Receiver Operator Characteristic &#40;ROC&#41; curve&#44; and the Area Under the ROC &#40;AUROC&#41; curve was computed&#46; The ROC graph for each variable was a plot of all the sensibility&#47;specificity pairs resulting from different cut-off points of mortality prediction&#46; AUROC close to 1 was considered as a &#8220;perfect&#8221; prediction model&#44; whilst values close to 0&#46;5 were considered poor prediction models&#46; Difference between AUROC was obtained by Hanley and McNeil analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Statistical significance was defined as <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">Nineteen patients with severe CAP were enrolled over an 18-month period&#46; Baseline characteristics are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Patients were relatively young&#44; with a moderate degree of severity of illness and an expected mortality of between 20 and 25&#37;&#46; The ICU crude mortality was 21&#46;1&#37;&#46; No significantly differences were observed between survivors and non-survivors&#46; Only mechanical ventilation &#40;MV&#41; and the presence of shock at ICU admission were variables associated with mortality&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The rSO<span class="elsevierStyleInf">2</span> mean value at ICU admission was significantly higher in deltoid muscle than in brachioradialis muscle &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; This trend was also found after 24<span class="elsevierStyleHsp" style=""></span>h of treatment &#40;65&#46;8 &#91;12&#46;6&#93; vs&#46; 69&#46;4 &#91;10&#46;5&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;19&#41;&#46; Measurements performed in both limbs allowed us to assess the variability due to this factor for each muscle&#46; Thus&#44; rSO<span class="elsevierStyleInf">2</span> values obtained simultaneously in left and right brachioradialis muscle showed a strong and significant direct correlation &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;95&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#44; and an adequate consistency &#40;ICC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;94&#59; 95&#37; CI&#58;0&#46;90&#8211;0&#46;96&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Similar results were observed for deltoid muscle <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;88&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41; and ICC of 0&#46;88 &#40;95&#37; CI&#58; 0&#46;80&#8211;0&#46;90&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; The precision of the measurements obtained simultaneously in both muscular groups was good&#44; with a coefficient of variation of 3&#46;68&#37; and 4&#46;38&#37; for brachioradialis and deltoid muscles&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">On the other hand&#44; there was a good correlation between simultaneous grouped measurements of rSO<span class="elsevierStyleInf">2</span> between deltoid and brachioradialis muscle &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;78&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The consistency of results was good &#40;ICC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;84&#59; 95&#37; CI&#58; 0&#46;77&#8211;0&#46;89&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#59; however the Bland&#8211;Altman analysis shows a mean difference of &#8722;4&#46;1 percentage points with a wide limit of agreement &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Non-survivors &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41; had values of rSO<span class="elsevierStyleInf">2</span> significantly lower than survivors&#44; both at admission and at 24<span class="elsevierStyleHsp" style=""></span>h &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; Among non-survivor patients&#44; rSO<span class="elsevierStyleInf">2</span> values in deltoid muscle were higher than brachioradialis muscle &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; In contrast&#44; there were no significant differences in rSO<span class="elsevierStyleInf">2</span> between the two muscle groups in survivors&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">According to our previous findings<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> a threshold of rSO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60&#37; in brachioradialis muscle on ICU admission was considered as &#8220;low&#8221; skeletal muscle oxygenation and associated with an unfavourable prognosis&#46; No patients with brachioradialis rSO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>60&#37; died&#46; In contrast&#44; 3 of 17 &#40;17&#46;6&#37;&#41; patients with deltoid rSO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>60&#37; finally died&#46; The presence of a low rSO<span class="elsevierStyleInf">2</span> &#40;&#60;60&#37;&#41; at ICU admission was associated with a mortality rate of 57&#37; and 50&#37; for brachioradialis and deltoid muscle respectively&#46; Finally&#44; even though both skeletal muscles showed consistent mortality discrimination&#44; the AUROC curve was superior in brachioradialis values at admission and at 24<span class="elsevierStyleHsp" style=""></span>h &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46; However&#44; this difference does not reach statistical significance neither at ICU admission &#40;<span class="elsevierStyleItalic">z</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;81&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;41&#41; nor at 24<span class="elsevierStyleHsp" style=""></span>h &#40;<span class="elsevierStyleItalic">z</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;28&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;77&#41;&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">This is the first study to compare rSO<span class="elsevierStyleInf">2</span> values obtained simultaneously in proximal and distal skeletal muscle areas of the limbs in patients with respiratory sepsis&#46; Sepsis causes microcirculatory derangement&#44; characterized by decreased vascular density&#44; a large number of non-perfused and intermittently perfused vessels and heterogeneity of capillary transit time with an increase in the proportion of fast-flow to normal-flow times&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;15&#44;16</span></a> Our results suggest that the distal muscular area &#40;brachioradialis muscle&#41; might better reflect changes in tissue oxygenation than the proximal muscular area &#40;deltoid muscle&#41; during the first 24<span class="elsevierStyleHsp" style=""></span>h of treatment in the ICU&#44; with no differences between the left and right sides of the body&#46; In addition&#44; our findings reinforce the concept that a major alteration in the muscle tissue oxygenation assessed by NIRS is associated with a worse prognosis&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Non-invasive determination of rSO<span class="elsevierStyleInf">2</span> in skeletal brachioradialis muscle has been proposed as a useful tool not only to quantify microvascular dysfunction&#44; but also to predict the evolution of critically ill patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;7&#44;17&#8211;20</span></a> Our group has reported that values of brachioradialis rSO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60&#37; at ICU admission are associated with a significant increase in mortality in septic patients&#46; These findings are confirmed in the present study&#44; focused on patients with respiratory sepsis&#46; Nevertheless&#44; sepsis physiopathology brings about alterations in tissue oxygenation&#44; due to an imbalance between supply and demand&#44; and can be heterogeneous in different sites&#46; Even though some factors related to oxygen supply are relatively homogeneous &#40;i&#46;e&#46; concentration and saturation of haemoglobin&#41;&#44; others like perfusion may vary depending on local factors&#46; Factors related to oxygen muscle utilization&#44; such as tissue bioenergetics&#44; muscle fibre composition&#44; enzymatic aerobic activity and myoglobin concentration might be determinant of the heterogeneity of this metabolic imbalance&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Another important finding was that skeletal rSO<span class="elsevierStyleInf">2</span> values were higher in deltoid muscle than brachioradialis muscle over the entire study period&#44; although there was a good correlation and concordance between them&#59; the Bland&#8211;Altman plot evidences a wide limit of agreement&#46; This suggest that rSO<span class="elsevierStyleInf">2</span> in deltoid muscle cannot be used in place of the rSO<span class="elsevierStyleInf">2</span> brachioradialis determination&#46; These differences might be explained by the different metabolic activity of each muscle dependent not only on the composition of the muscle fibres &#40;oxidative or glycolytic&#41; but also the different capillary density&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> To our knowledge&#44; no studies have been published on capillary density of each muscular group&#46; However&#44; we know the phenotype of muscle fibres in humans for brachioradialis muscle &#40;40&#37; type I fibres&#41; and deltoid &#40;48&#37; type I fibres&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> We could speculate that this characteristic might result in a slightly smaller number of capillaries in brachioradialis muscle compared to deltoid&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;25</span></a> A different vascular reactivity resulting from sepsis could also be a differential element between the two muscle territories&#46; Considering that this is one of the elements that can be inferred with NIRS technology&#44; it is necessary to standardize measurement of the signal site&#46; On the other hand&#44; the prognostic value of the variables obtained depends on the sensitivity to changes they reflect&#46; Our hypothesis was that these changes would be more marked in distal skeletal muscle territories&#44; and our results support this idea&#46; However&#44; the discriminatory ability for mortality was similar for the rSO<span class="elsevierStyleInf">2</span> brachioradialis and deltoid muscle determinations&#46; Given the difficulty of carrying out measurements in brachioradialis for anatomical or functional reasons &#40;i&#46;e&#46; presence of catheters on the forearm&#41;&#44; the deltoid might be a second option for patients with community-acquired respiratory sepsis&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Finally&#44; another important finding of our study was the close association between early lower values of rSO<span class="elsevierStyleInf">2</span> and mortality in both muscles&#46; These results are consistent with previous findings published by Ikossi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> using another NIRS device &#40;the InSpectra&#44; Hutchinson Technology&#44; Minneapolis&#44; MN&#44; USA&#41;&#46; These authors analyzed 28 critically ill patients after a resuscitation period&#44; and obtained mean values of tissue oxygen saturation &#40;StO<span class="elsevierStyleInf">2</span>&#41; in the deltoid of 63&#37;&#44; similar to the one observed in our patients &#40;68&#37; at admission&#41;&#46; In addition&#44; StO<span class="elsevierStyleInf">2</span> values closely correlated with tissue oxygen pressure measured directly on the muscle&#46; Both variables were associated with development of complications&#46; Furthermore&#44; animal models of haemorrhagic shock<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> have shown an excellent correlation between liver and muscular &#40;deltoid&#41; tissue oxygenation&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The fact that we obtained discriminatory prognostic values without carrying out a vascular occlusion test &#40;VOT&#41; is an interesting finding of the present study that confirm what our group have previously reported&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Some authors suggest that performing a VOT &#40;interruption of the blood flow through the forearm with a pressure cuff for 3<span class="elsevierStyleHsp" style=""></span>min&#41; is a more appropriate way to assess the functionality of vascular response&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> It is not possible to realize this test in the deltoid muscle&#46; In addition&#44; the main objective of the present study was to compare rSO<span class="elsevierStyleInf">2</span> values obtained simultaneously in two muscular groups&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">As a collateral finding&#44; our results suggest that there are no significant differences between the rSO<span class="elsevierStyleInf">2</span> measured in both upper limbs&#46; Physiologically&#44; this would be due to the predictable symmetry of the factors that influence the state of tissue oxygenation&#46; The clinical conclusion would be that&#44; in the absence of local factors that contraindicate it&#44; measurements are the same for both sides of the body&#46; It also indicates that it is not necessary to obtain the measurements in the dominant limb&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;18</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The present study has several limitations that should be addressed&#44; even though the relevance of the findings is not challenged&#46; First of all&#44; there was no control group because our group had already validated rSO<span class="elsevierStyleInf">2</span> measurement techniques in healthy controls&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This study only intended to compare the performance of the measurement of the rSO<span class="elsevierStyleInf">2</span> carried out in different skeletal muscle locations&#46; A second potential limitation is the small sample size&#59; therefore results need to be interpreted with caution especially those related to prognosis&#46; However&#44; results reach significance in a homogeneous group of patients &#40;CAP patients&#41; which confers internal validity&#46; Finally&#44; we were not able to carry out either morphological or metabolic tests in the muscles studied&#44; which could have explained the differences observed in rSO<span class="elsevierStyleInf">2</span> values&#46; The clinical condition of septic patients makes it difficult to conduct muscular biopsies&#46; Even so&#44; members of our group have recently published a paper about metabolic alterations that can be found in respiratory and lower limb muscles in septic patients&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">In conclusion&#44; our results reinforce the potential usefulness of the rSO<span class="elsevierStyleInf">2</span> in the assessment of the severity and prognosis of patients with community respiratory sepsis&#46; Brachioradialis and deltoid muscle were appropriate for measuring this variable&#46; Furthermore&#44; there were no significant differences between each side of the body&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Author contributions</span><p id="par0130" class="elsevierStylePara elsevierViewall">Rodriguez A&#44; Mar&#237;n J&#44; Claverias L&#44; Magret M&#44; Bodi M&#44; Cos E&#44; Rosich S&#44; Trefler S and Pascual S have made substantial contributions to conception and design&#44; acquisition&#44; analysis and interpretation of data&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Rodriguez A has drafted the submitted article&#46; Mar&#237;n L&#44; Claverias L&#44; Pascual S and Gea J have revised the manuscript critically for important intellectual content&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Rodriguez A and Gea J have provided final approval of the version to be published&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflicts of interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to disclose&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Funding</span><p id="par0150" class="elsevierStylePara elsevierViewall">This study was partially supported by grants from the <span class="elsevierStyleGrantSponsor" id="gs0005">Fondo de Investigaci&#243;n Sanitaria</span> &#40;FIS <span class="elsevierStyleGrantNumber" refid="gs0005">PI10&#47;01538</span> and <span class="elsevierStyleGrantNumber" refid="gs0005">PI13&#47;02011</span>&#41; and <span class="elsevierStyleGrantSponsor" id="gs0010">Beca SEPAR</span><span class="elsevierStyleGrantNumber" refid="gs0010">264&#47;2012</span>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The funding agency had no role in study design&#44; in collection&#44; analysis or interpretation of data&#59; in writing of the manuscript&#59; or in the decision to submit the paper for publication&#46; The content is solely the responsibility of the authors and does not necessarily represent the official views of the Institute of Health Carlos III &#40;ISC III&#41; and SEPAR from Spain&#46;</p></span></span>"
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          "titulo" => "Materials and methods"
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            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Patients"
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            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Procedures"
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              "identificador" => "sec0025"
              "titulo" => "Statistical analysis"
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          "titulo" => "Results"
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          "titulo" => "Discussion"
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          "identificador" => "sec0040"
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          "titulo" => "Conflicts of interest"
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          "identificador" => "sec0050"
          "titulo" => "Funding"
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        11 => array:2 [
          "identificador" => "xack284372"
          "titulo" => "Acknowledgments"
        ]
        12 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2013-07-10"
    "fechaAceptado" => "2013-12-09"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec842339"
          "palabras" => array:5 [
            0 => "Microcirculation"
            1 => "Spectroscopy"
            2 => "Near-infrared"
            3 => "Community-acquired pneumonia"
            4 => "Tissue oxygenation"
          ]
        ]
      ]
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        0 => array:4 [
          "clase" => "keyword"
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          "identificador" => "xpalclavsec842340"
          "palabras" => array:4 [
            0 => "Microcirculaci&#243;n"
            1 => "Espectroscopia cercana al infrarrojo"
            2 => "Neumon&#237;a comunitaria"
            3 => "Oxigenaci&#243;n tisular"
          ]
        ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To compare oxygen saturation index &#40;rSO<span class="elsevierStyleInf">2</span>&#41; obtained simultaneously in two different brachial muscles&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Prospective and observational study&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Setting</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Intensive care unit&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Patients</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Critically ill patients with community-acquired pneumonia&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Interventions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Two probes of NIRS device &#40;INVOS 5100&#41; were simultaneously placed on the brachioradialis &#40;BR&#41; and deltoid &#40;D&#41; muscles&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Variables</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">rSO<span class="elsevierStyleInf">2</span> measurements were recorded at baseline &#40;ICU admission&#41; and at 24<span class="elsevierStyleHsp" style=""></span>h&#46; Demographic and clinical variables were registered&#46; Pearson&#39;s correlation coefficient was used to assess the association between continuous variables&#46; The consistency of the correlation was assessed using the intraclass correlation coefficient &#40;ICC&#41; and Bland&#8211;Altman plot&#46; The predictive value of the rSO<span class="elsevierStyleInf">2</span> for mortality was calculated by ROC curve&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Nineteen patients were included with an ICU mortality of 21&#46;1&#37;&#46; The rSO<span class="elsevierStyleInf">2</span> values at baseline and at 24<span class="elsevierStyleHsp" style=""></span>h were significantly higher in D than in BR muscle&#46; Values obtained simultaneously in both limbs showed a strong correlation and adequate consistency&#58; BR &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;95&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#59; ICC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;94&#59; 95&#37; CI&#58; 0&#46;90&#8211;0&#46;96&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; D &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;88&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#59; ICC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;88&#59; 95&#37; CI&#58; 0&#46;80&#8211;0&#46;90&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; but a wide limit of agreement&#46; Non-survivors had rSO<span class="elsevierStyleInf">2</span> values significantly lower than survivors at all times of the study&#46; No patient with rSO<span class="elsevierStyleInf">2</span> &#62;60&#37; in BR died&#44; and only 17&#46;6&#37; died with an rSO<span class="elsevierStyleInf">2</span> value &#62;60&#37; in D&#46; Both muscles showed consistent discriminatory power for mortality&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Both BR and D muscles were appropriate for measuring rSO<span class="elsevierStyleInf">2</span>&#46;</p></span>"
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            "titulo" => "Design"
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            "titulo" => "Patients"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Objetivo</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Comparar el &#237;ndice de saturaci&#243;n tisular de ox&#237;geno &#40;rSO<span class="elsevierStyleInf">2</span>&#41; medido de forma simult&#225;nea en 2 diferentes m&#250;sculos braquiales&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Dise&#241;o</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo&#44; observacional&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">&#193;mbito</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Servicio de Medicina Intensiva&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pacientes</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Cr&#237;ticos con neumon&#237;a comunitaria&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Intervenciones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Dos sensores con tecnolog&#237;a NIRS &#40;INVOS&#8482; 5100&#41; fueron ubicados de forma simult&#225;nea en los m&#250;sculos braquiorradial &#40;BR&#41; y deltoides &#40;D&#41;&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Variables</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Las mediciones del rSO<span class="elsevierStyleInf">2</span> se efectuaron al ingreso &#40;basal&#41; y a las 24<span class="elsevierStyleHsp" style=""></span>h&#46; Se registraron los datos demogr&#225;ficos y cl&#237;nicos&#46; La correlaci&#243;n de Pearson se utiliz&#243; para estudiar la asociaci&#243;n entre variables continuas&#46; La concordancia de la correlaci&#243;n fue valorada mediante el coeficiente de correlaci&#243;n intraclase &#40;ICC&#41; y el an&#225;lisis de Bland-Altman&#46; El valor predictivo de rSO<span class="elsevierStyleInf">2</span> para mortalidad fue calculado mediante curva ROC&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 19 pacientes con una mortalidad de 21&#44;1&#37;&#46; El valor basal y a las 24<span class="elsevierStyleHsp" style=""></span>h de rSO<span class="elsevierStyleInf">2</span> fue significativamente mayor en D respecto del BR&#46; Los valores obtenidos de forma simult&#225;nea en ambos miembros evidenciaron una buena correlaci&#243;n y una adecuada concordancia&#58; BR &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;95&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#46; ICC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;94&#59; IC 95&#37;&#58; 0&#44;90-0&#44;96&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; D &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;88&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#46; ICC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;88&#59; IC 95&#37;&#58; 0&#44;80-0&#44;90&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; as&#237; como un amplio rango de concordancia&#46; Los fallecidos presentaron valores de rSO<span class="elsevierStyleInf">2</span> significativamente menores que los supervivientes en todos los momentos del estudio&#46; Ning&#250;n paciente con rSO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>60&#37; en BR falleci&#243;&#44; y solo el 17&#44;6&#37; fallecieron con un rSO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>60&#37; en D&#46; Ambos m&#250;sculos evidenciaron un buen poder de discriminaci&#243;n para mortalidad&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Tanto el m&#250;sculo BR como el D fueron apropiados para la medici&#243;n del rSO<span class="elsevierStyleInf">2</span>&#46;</p></span>"
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          "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Correlation between simultaneous grouped measurements of rSO<span class="elsevierStyleInf">2</span> in brachioradialis and deltoid muscle&#46;</p>"
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          "en" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Comparison of regional oxygen saturation index &#40;rSO<span class="elsevierStyleInf">2</span>&#41; in brachioradialis and deltoid muscles &#40;Bland&#8211;Altman analysis&#41;&#46;</p>"
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          "en" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Area Under Receiver Operating Characteristic &#40;AUROC&#41; curves for skeletal muscle rSO<span class="elsevierStyleInf">2</span> in brachioradialis and deltoid muscle at ICU admission &#40;baseline&#41; and at 24<span class="elsevierStyleHsp" style=""></span>h for mortality&#46;</p>"
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          "leyenda" => "<p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">SD&#58; standard deviation&#59; APACHE II&#58; Acute Physiologic Physiology and Chronic Health Evaluation II&#59; ICU&#58; intensive care unit&#59; SOFA&#58; sequential organ failure assessment&#59; SAPS 3&#58; Simplified Acute Physiology Score 3&#59; NA&#58; not applicable&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">All patients &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Survivors &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Non-survivors &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-Value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Age &#40;yr&#41;&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&#46;0 &#40;16&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">52&#46;9 &#40;17&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&#46;0 &#40;14&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Men&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;73&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 &#40;80&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;50&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">APACHE II score at day-1&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;6 &#40;6&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#46;2 &#40;3&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&#46;0 &#40;10&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">SAPS 3 score at day-1&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">52&#46;2 &#40;7&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">51&#46;1 &#40;6&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56&#46;0 &#40;9&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">SOFA at day-1&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;2 &#40;1&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;9 &#40;1&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;0 &#40;3&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">ICU length of stay &#40;days&#41;&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;6 &#40;13&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;6 &#40;10&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#46;1 &#40;23&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;23&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;47&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 &#40;33&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Shock at day-1&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;47&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 &#40;33&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">ICU mortality rate&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;21&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Baseline characteristic of the 19 patients with respiratory sepsis included in the study&#46;</p>"
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">66&#46;9 &#40;8&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70&#46;3 &#40;6&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&#46;7 &#40;3&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60&#46;6 &#40;6&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73&#46;5 &#40;8&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&#46;4 &#40;5&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">56&#46;2 &#40;5&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;01&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">Skeletal regional saturation index &#40;rSO<span class="elsevierStyleInf">2</span>&#41; in brachioradialis and deltoid muscle at ICU admission and at 24<span class="elsevierStyleHsp" style=""></span>h in survivors and non-survivors&#46;</p>"
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    ]
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:28 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
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                  "contribucion" => array:1 [
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00134-007-0739-3"
                      "Revista" => array:6 [
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            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                            1 => "M&#46;M&#46; Knudson"
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            2 => array:3 [
              "identificador" => "bib0015"
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                  "contribucion" => array:1 [
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                            1 => "T&#46; Lisboa"
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                      "doi" => "10.1097/TA.0b013e318216f72c"
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            3 => array:3 [
              "identificador" => "bib0020"
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              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                  "host" => array:1 [
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                      "doi" => "10.1093/bja/aep299"
                      "Revista" => array:7 [
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20007987"
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            4 => array:3 [
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                0 => array:2 [
                  "contribucion" => array:1 [
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                            0 => "H&#46; Gomez"
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                  "host" => array:1 [
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                  "contribucion" => array:1 [
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                            0 => "R&#46; Bezemer"
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                          "autores" => array:6 [
                            0 => "M&#46; Bod&#237;"
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            ]
            8 => array:3 [
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Infectious Diseases Society of America&#47;American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults&#46; Infectious Diseases Society of America&#59; American Thoracic Society"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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Original
Regional oxygen saturation index (rSO2) in brachioradialis and deltoid muscle. Correlation and prognosis in patients with respiratory sepsis
Índice de saturación tisular de oxígeno en los músculos braquiorradial y deltoides. Correlación y pronóstico en pacientes con sepsis respiratoria
A. Rodrígueza,b,c,
Autor para correspondencia
, L. Claveriasa, J. Marína, M. Magreta, S. Rosicha, M. Bodía,b,c, S. Treflera,b, S. Pascualc,d, J. Geac,d
a Critical Care Department, Hospital Universitario de Tarragona Joan XXIII, Tarragona, Spain
b Institut d’Investigació Sanitaria Pere Virgili, Universitat Rovira i Virgili, Tarragona, Spain
c Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Bunyola, Mallorca, Spain
d Department of CEXS, UPF, Servicio de Neumología, Hospital del Mar-IMIM, Barcelona, Spain
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          "en" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Area Under Receiver Operating Characteristic &#40;AUROC&#41; curves for skeletal muscle rSO<span class="elsevierStyleInf">2</span> in brachioradialis and deltoid muscle at ICU admission &#40;baseline&#41; and at 24<span class="elsevierStyleHsp" style=""></span>h for mortality&#46;</p>"
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However&#44; StO<span class="elsevierStyleInf">2</span> is defined as a quantification of the OxyHb&#47;HbT ratio in microcirculation of skeletal muscle as an absolute number&#46; On the other hand&#44; skeletal rSO<span class="elsevierStyleInf">2</span> is an index of OxyHb present within a volume of tissue&#59; this index is expressed as the percentage of oxygenated haemoglobin relative to total haemoglobin &#40;HbO<span class="elsevierStyleInf">2</span>&#47;Hb sum&#41;&#46; The INVOS 510 devices employ reflectance mode probes that have one 1&#46;5<span class="elsevierStyleHsp" style=""></span>mm optical fibre to illuminate the tissue and two optical fibres &#40;30<span class="elsevierStyleHsp" style=""></span>mm and 40<span class="elsevierStyleHsp" style=""></span>mm&#41; to detect the backscattered light from the tissue&#46; The 40<span class="elsevierStyleHsp" style=""></span>mm separated fibre measures a greater and deeper tissue volume than the 30<span class="elsevierStyleHsp" style=""></span>mm separated fibre&#46; The difference between the spectral absorbance measured with these two probing depths is used to calculate rSO<span class="elsevierStyleInf">2</span>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Nevertheless&#44; this technique has some difficulties&#44; mainly due to the lack of signal processing and acquisition procedures standardization&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> The first problem arises from the difficulty of establishing a relationship between the two variables and comparing data obtained with different devices&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Moreover&#44; there is no standard application site for measurements&#46; Therefore&#44; using different muscles may derive different values of the variables&#46; These differences might be related&#44; to the local perfusion characteristics &#40;including its response to different stimulus&#41;&#44; the different metabolic functions and states&#44; and the morphological characteristics of each muscle&#44; among others&#46; In this regard&#44; Bezemer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> reported that forearm StO<span class="elsevierStyleInf">2</span> is a more sensitive parameter to haemodynamic changes than thenar StO<span class="elsevierStyleInf">2</span> and that the depth at which StO<span class="elsevierStyleInf">2</span> is measured is of minor influence&#46; On the other hand&#44; Ikossi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> found no association between StO<span class="elsevierStyleInf">2</span> and tissue oxygen pressure &#40;measured directly with electrodes&#41; in deltoid muscle&#46; Recently&#44; our group reported that a brachioradialis rSO<span class="elsevierStyleInf">2</span> greater than 60&#37; at ICU admission was associated with better outcome in septic patients&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The skeletal rSO<span class="elsevierStyleInf">2</span> seems to be an adequate variable for evaluating the microvascular status in patients with severe sepsis&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> However&#44; the site of application is important because there may be differences in the sensitivity of underlying muscle groups and other anatomical structures&#44; to cardiovascular challenges&#46; Unfortunately&#44; there are no studies that have determined rSO<span class="elsevierStyleInf">2</span> in different application sites simultaneously using INVOS 5100 spectroscopy technology&#46; We believe that contributing to clarifying these differences may be helpful in the management of critically ill patients&#44; particularly in those where it is crucial to try to maintain the balance between oxygen supply and demand&#46; The aim of this study was to investigate rSO<span class="elsevierStyleInf">2</span> behaviour in two different brachial muscles in septic patients&#44; a proximal one &#40;deltoid muscle&#44; D&#41; and a distal one &#40;brachioradialis muscle&#44; BR&#41;&#46; The measurements were obtained initially at ICU admission and again 24<span class="elsevierStyleHsp" style=""></span>h after starting the treatment&#46; The specific objectives of the study were&#58; &#40;1&#41; To compare rSO<span class="elsevierStyleInf">2</span> values obtained during the evolution of the patient and simultaneously in both muscles and &#40;2&#41; to determine the association between those values and ICU mortality&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Materials and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">A prospective and observational study was conducted in a 30-bed medical&#8211;surgical ICU in a tertiary university hospital&#46; The investigation was conducted according to the principles outlined in the Declaration of Helsinki&#46; The study protocol was approved by the Joan XXIII University Hospital Ethics Committee &#40;MICRO2 20&#47;2010&#41; and informed consent was given by each patient or their next of kin&#46; Data obtained from rSO<span class="elsevierStyleInf">2</span> were not known by the care team and did not influence any decision about treatment or management&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Patients</span><p id="par0030" class="elsevierStylePara elsevierViewall">Since patients with sepsis are heterogeneous&#44; this study included only those with severe sepsis due to community-acquired pneumonia &#40;CAP&#41;&#46; Inclusion criteria were&#58; &#40;1&#41; severe CAP&#59; &#40;2&#41; age &#62;18 years&#59; &#40;3&#41; less than 6<span class="elsevierStyleHsp" style=""></span>h between ICU admission and the first measurement&#59; and &#40;4&#41; informed consent obtained from patients or relatives&#46; Patients with morbid obesity &#40;Corporal Mass Index &#62;30<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41; were excluded&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Severe CAP was defined as an acute lower tract infection characterized by&#58; &#40;1&#41; an acute pulmonary infiltrate evident on chest radiographs and compatible with pneumonia&#44; &#40;2&#41; confirmatory findings of clinical examination&#44; &#40;3&#41; acquisition of the infection outside a hospital&#44; long-term care facility or nursing home<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#44; and &#40;4&#41; ICU admission&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Procedures</span><p id="par0040" class="elsevierStylePara elsevierViewall">Once the patient has been enrolled&#44; demographic variables were registered and severity of illness was assessed using Acute Physiology and Chronic Health Evaluation II &#40;APACHE II&#41;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#59; Sequential Organ Failure Assessment score &#40;SOFA&#41;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and Simplified Acute Physiology Score 3 &#40;SAPS 3&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The rSO<span class="elsevierStyleInf">2</span> measurements were taken by NIRS using system INVOS 5100 &#40;Somanetics Corporation&#44; Troy&#44; MI&#44; USA&#41;&#44; by the technique previously described&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Briefly&#44; NIRS is a non-invasive technique that uses the differential absorption properties of oxygenated and deoxygenated haemoglobin to evaluate tissue oxygenation&#46; The near-infrared light easily crosses biological tissues&#44; which have a low absorption power&#44; and is absorbed only by haemoglobin&#44; myoglobin and oxidized cytochrome&#44; although the contribution of these latter two to the light attenuation signal is very small&#46; The NIRS INVOS system signal is limited to vessels that have less than 1<span class="elsevierStyleHsp" style=""></span>mm &#40;arterioles&#44; capillary and venules&#41;&#44; since the elevated blood concentration of vessels with greater diameter &#40;and greater light absorption&#41; makes the reflection less probable&#46; The NIRS INVOS technique uses reflectance mode probes that have one 1&#46;5-mm optical fibre to illuminate the tissue to a depth of 4<span class="elsevierStyleHsp" style=""></span>cm&#44; and two optical fibres to detect the backscattered light from the tissue&#46; The signal is then transformed to a digital absolute number &#40;rSO<span class="elsevierStyleInf">2</span>&#41; and carried to a display unit where the values and trends are displayed on the screen&#46; The system updates the rSO<span class="elsevierStyleInf">2</span> value at 10<span class="elsevierStyleHsp" style=""></span>s intervals&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In all patients&#44; two probes were placed on the brachioradialis muscle&#44; located on the anterior outside of the forearm&#44; 1&#8211;2<span class="elsevierStyleHsp" style=""></span>cm below its insertion on the external tip of the radius in both limbs&#44; according to the technique describe by Bezemer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> At the same time&#44; another two probes were placed on the deltoid muscle in both limbs&#44; 1&#8211;2<span class="elsevierStyleHsp" style=""></span>cm below the acromioclavicular joint&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> After a stabilization period of 30&#8211;40<span class="elsevierStyleHsp" style=""></span>s&#44; values for rSO<span class="elsevierStyleInf">2</span> were registered for each of the studied muscles&#46; Measurements were recorded at baseline &#40;ICU admission&#41; and 24<span class="elsevierStyleHsp" style=""></span>h after initiating treatment&#46; No vascular occlusion test was carried out in this study &#40;see &#8216;Discussion&#8217; section&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Statistical analysis</span><p id="par0055" class="elsevierStylePara elsevierViewall">Differences between groups were assessed using chi-square or Fisher&#39;s exact test for discrete variables and the Wilcoxon test and analysis of variance &#40;ANOVA&#41;&#46; The precision of the measurements obtained in both muscle groups was studied through the determination of the coefficient of variation &#40;CV&#41;&#46; Pearson&#39;s correlation coefficient was used to assess the association between continuous variables&#46; The consistency of the values obtained in different application sites was assessed using the intraclass correlation coefficient &#40;ICC&#41;&#44; based on the model of analysis of variance for repeated measures by the process reliability&#46; The strength of the consistency was assessed according to the value of the ICC as&#44; very good &#40;&#62;0&#46;90&#41;&#44; good &#40;0&#46;71&#8211;0&#46;90&#41;&#44; moderate &#40;0&#46;51&#8211;0&#46;70&#41;&#44; mediocre &#40;0&#46;31&#8211;0&#46;50&#41; and null &#40;&#60;0&#46;30&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> In addition&#44; Bland&#8211;Altman analysis was performed&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The predictive value of the variables for mortality was calculated using the Receiver Operator Characteristic &#40;ROC&#41; curve&#44; and the Area Under the ROC &#40;AUROC&#41; curve was computed&#46; The ROC graph for each variable was a plot of all the sensibility&#47;specificity pairs resulting from different cut-off points of mortality prediction&#46; AUROC close to 1 was considered as a &#8220;perfect&#8221; prediction model&#44; whilst values close to 0&#46;5 were considered poor prediction models&#46; Difference between AUROC was obtained by Hanley and McNeil analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Statistical significance was defined as <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">Nineteen patients with severe CAP were enrolled over an 18-month period&#46; Baseline characteristics are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Patients were relatively young&#44; with a moderate degree of severity of illness and an expected mortality of between 20 and 25&#37;&#46; The ICU crude mortality was 21&#46;1&#37;&#46; No significantly differences were observed between survivors and non-survivors&#46; Only mechanical ventilation &#40;MV&#41; and the presence of shock at ICU admission were variables associated with mortality&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The rSO<span class="elsevierStyleInf">2</span> mean value at ICU admission was significantly higher in deltoid muscle than in brachioradialis muscle &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; This trend was also found after 24<span class="elsevierStyleHsp" style=""></span>h of treatment &#40;65&#46;8 &#91;12&#46;6&#93; vs&#46; 69&#46;4 &#91;10&#46;5&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;19&#41;&#46; Measurements performed in both limbs allowed us to assess the variability due to this factor for each muscle&#46; Thus&#44; rSO<span class="elsevierStyleInf">2</span> values obtained simultaneously in left and right brachioradialis muscle showed a strong and significant direct correlation &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;95&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#44; and an adequate consistency &#40;ICC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;94&#59; 95&#37; CI&#58;0&#46;90&#8211;0&#46;96&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Similar results were observed for deltoid muscle <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;88&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41; and ICC of 0&#46;88 &#40;95&#37; CI&#58; 0&#46;80&#8211;0&#46;90&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; The precision of the measurements obtained simultaneously in both muscular groups was good&#44; with a coefficient of variation of 3&#46;68&#37; and 4&#46;38&#37; for brachioradialis and deltoid muscles&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">On the other hand&#44; there was a good correlation between simultaneous grouped measurements of rSO<span class="elsevierStyleInf">2</span> between deltoid and brachioradialis muscle &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;78&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The consistency of results was good &#40;ICC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;84&#59; 95&#37; CI&#58; 0&#46;77&#8211;0&#46;89&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#59; however the Bland&#8211;Altman analysis shows a mean difference of &#8722;4&#46;1 percentage points with a wide limit of agreement &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Non-survivors &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41; had values of rSO<span class="elsevierStyleInf">2</span> significantly lower than survivors&#44; both at admission and at 24<span class="elsevierStyleHsp" style=""></span>h &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; Among non-survivor patients&#44; rSO<span class="elsevierStyleInf">2</span> values in deltoid muscle were higher than brachioradialis muscle &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; In contrast&#44; there were no significant differences in rSO<span class="elsevierStyleInf">2</span> between the two muscle groups in survivors&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">According to our previous findings<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> a threshold of rSO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60&#37; in brachioradialis muscle on ICU admission was considered as &#8220;low&#8221; skeletal muscle oxygenation and associated with an unfavourable prognosis&#46; No patients with brachioradialis rSO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>60&#37; died&#46; In contrast&#44; 3 of 17 &#40;17&#46;6&#37;&#41; patients with deltoid rSO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>60&#37; finally died&#46; The presence of a low rSO<span class="elsevierStyleInf">2</span> &#40;&#60;60&#37;&#41; at ICU admission was associated with a mortality rate of 57&#37; and 50&#37; for brachioradialis and deltoid muscle respectively&#46; Finally&#44; even though both skeletal muscles showed consistent mortality discrimination&#44; the AUROC curve was superior in brachioradialis values at admission and at 24<span class="elsevierStyleHsp" style=""></span>h &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46; However&#44; this difference does not reach statistical significance neither at ICU admission &#40;<span class="elsevierStyleItalic">z</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;81&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;41&#41; nor at 24<span class="elsevierStyleHsp" style=""></span>h &#40;<span class="elsevierStyleItalic">z</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;28&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;77&#41;&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">This is the first study to compare rSO<span class="elsevierStyleInf">2</span> values obtained simultaneously in proximal and distal skeletal muscle areas of the limbs in patients with respiratory sepsis&#46; Sepsis causes microcirculatory derangement&#44; characterized by decreased vascular density&#44; a large number of non-perfused and intermittently perfused vessels and heterogeneity of capillary transit time with an increase in the proportion of fast-flow to normal-flow times&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;15&#44;16</span></a> Our results suggest that the distal muscular area &#40;brachioradialis muscle&#41; might better reflect changes in tissue oxygenation than the proximal muscular area &#40;deltoid muscle&#41; during the first 24<span class="elsevierStyleHsp" style=""></span>h of treatment in the ICU&#44; with no differences between the left and right sides of the body&#46; In addition&#44; our findings reinforce the concept that a major alteration in the muscle tissue oxygenation assessed by NIRS is associated with a worse prognosis&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Non-invasive determination of rSO<span class="elsevierStyleInf">2</span> in skeletal brachioradialis muscle has been proposed as a useful tool not only to quantify microvascular dysfunction&#44; but also to predict the evolution of critically ill patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;7&#44;17&#8211;20</span></a> Our group has reported that values of brachioradialis rSO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60&#37; at ICU admission are associated with a significant increase in mortality in septic patients&#46; These findings are confirmed in the present study&#44; focused on patients with respiratory sepsis&#46; Nevertheless&#44; sepsis physiopathology brings about alterations in tissue oxygenation&#44; due to an imbalance between supply and demand&#44; and can be heterogeneous in different sites&#46; Even though some factors related to oxygen supply are relatively homogeneous &#40;i&#46;e&#46; concentration and saturation of haemoglobin&#41;&#44; others like perfusion may vary depending on local factors&#46; Factors related to oxygen muscle utilization&#44; such as tissue bioenergetics&#44; muscle fibre composition&#44; enzymatic aerobic activity and myoglobin concentration might be determinant of the heterogeneity of this metabolic imbalance&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Another important finding was that skeletal rSO<span class="elsevierStyleInf">2</span> values were higher in deltoid muscle than brachioradialis muscle over the entire study period&#44; although there was a good correlation and concordance between them&#59; the Bland&#8211;Altman plot evidences a wide limit of agreement&#46; This suggest that rSO<span class="elsevierStyleInf">2</span> in deltoid muscle cannot be used in place of the rSO<span class="elsevierStyleInf">2</span> brachioradialis determination&#46; These differences might be explained by the different metabolic activity of each muscle dependent not only on the composition of the muscle fibres &#40;oxidative or glycolytic&#41; but also the different capillary density&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> To our knowledge&#44; no studies have been published on capillary density of each muscular group&#46; However&#44; we know the phenotype of muscle fibres in humans for brachioradialis muscle &#40;40&#37; type I fibres&#41; and deltoid &#40;48&#37; type I fibres&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> We could speculate that this characteristic might result in a slightly smaller number of capillaries in brachioradialis muscle compared to deltoid&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;25</span></a> A different vascular reactivity resulting from sepsis could also be a differential element between the two muscle territories&#46; Considering that this is one of the elements that can be inferred with NIRS technology&#44; it is necessary to standardize measurement of the signal site&#46; On the other hand&#44; the prognostic value of the variables obtained depends on the sensitivity to changes they reflect&#46; Our hypothesis was that these changes would be more marked in distal skeletal muscle territories&#44; and our results support this idea&#46; However&#44; the discriminatory ability for mortality was similar for the rSO<span class="elsevierStyleInf">2</span> brachioradialis and deltoid muscle determinations&#46; Given the difficulty of carrying out measurements in brachioradialis for anatomical or functional reasons &#40;i&#46;e&#46; presence of catheters on the forearm&#41;&#44; the deltoid might be a second option for patients with community-acquired respiratory sepsis&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Finally&#44; another important finding of our study was the close association between early lower values of rSO<span class="elsevierStyleInf">2</span> and mortality in both muscles&#46; These results are consistent with previous findings published by Ikossi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> using another NIRS device &#40;the InSpectra&#44; Hutchinson Technology&#44; Minneapolis&#44; MN&#44; USA&#41;&#46; These authors analyzed 28 critically ill patients after a resuscitation period&#44; and obtained mean values of tissue oxygen saturation &#40;StO<span class="elsevierStyleInf">2</span>&#41; in the deltoid of 63&#37;&#44; similar to the one observed in our patients &#40;68&#37; at admission&#41;&#46; In addition&#44; StO<span class="elsevierStyleInf">2</span> values closely correlated with tissue oxygen pressure measured directly on the muscle&#46; Both variables were associated with development of complications&#46; Furthermore&#44; animal models of haemorrhagic shock<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> have shown an excellent correlation between liver and muscular &#40;deltoid&#41; tissue oxygenation&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The fact that we obtained discriminatory prognostic values without carrying out a vascular occlusion test &#40;VOT&#41; is an interesting finding of the present study that confirm what our group have previously reported&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Some authors suggest that performing a VOT &#40;interruption of the blood flow through the forearm with a pressure cuff for 3<span class="elsevierStyleHsp" style=""></span>min&#41; is a more appropriate way to assess the functionality of vascular response&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> It is not possible to realize this test in the deltoid muscle&#46; In addition&#44; the main objective of the present study was to compare rSO<span class="elsevierStyleInf">2</span> values obtained simultaneously in two muscular groups&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">As a collateral finding&#44; our results suggest that there are no significant differences between the rSO<span class="elsevierStyleInf">2</span> measured in both upper limbs&#46; Physiologically&#44; this would be due to the predictable symmetry of the factors that influence the state of tissue oxygenation&#46; The clinical conclusion would be that&#44; in the absence of local factors that contraindicate it&#44; measurements are the same for both sides of the body&#46; It also indicates that it is not necessary to obtain the measurements in the dominant limb&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;18</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The present study has several limitations that should be addressed&#44; even though the relevance of the findings is not challenged&#46; First of all&#44; there was no control group because our group had already validated rSO<span class="elsevierStyleInf">2</span> measurement techniques in healthy controls&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This study only intended to compare the performance of the measurement of the rSO<span class="elsevierStyleInf">2</span> carried out in different skeletal muscle locations&#46; A second potential limitation is the small sample size&#59; therefore results need to be interpreted with caution especially those related to prognosis&#46; However&#44; results reach significance in a homogeneous group of patients &#40;CAP patients&#41; which confers internal validity&#46; Finally&#44; we were not able to carry out either morphological or metabolic tests in the muscles studied&#44; which could have explained the differences observed in rSO<span class="elsevierStyleInf">2</span> values&#46; The clinical condition of septic patients makes it difficult to conduct muscular biopsies&#46; Even so&#44; members of our group have recently published a paper about metabolic alterations that can be found in respiratory and lower limb muscles in septic patients&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">In conclusion&#44; our results reinforce the potential usefulness of the rSO<span class="elsevierStyleInf">2</span> in the assessment of the severity and prognosis of patients with community respiratory sepsis&#46; Brachioradialis and deltoid muscle were appropriate for measuring this variable&#46; Furthermore&#44; there were no significant differences between each side of the body&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Author contributions</span><p id="par0130" class="elsevierStylePara elsevierViewall">Rodriguez A&#44; Mar&#237;n J&#44; Claverias L&#44; Magret M&#44; Bodi M&#44; Cos E&#44; Rosich S&#44; Trefler S and Pascual S have made substantial contributions to conception and design&#44; acquisition&#44; analysis and interpretation of data&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Rodriguez A has drafted the submitted article&#46; Mar&#237;n L&#44; Claverias L&#44; Pascual S and Gea J have revised the manuscript critically for important intellectual content&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Rodriguez A and Gea J have provided final approval of the version to be published&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflicts of interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to disclose&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Funding</span><p id="par0150" class="elsevierStylePara elsevierViewall">This study was partially supported by grants from the <span class="elsevierStyleGrantSponsor" id="gs0005">Fondo de Investigaci&#243;n Sanitaria</span> &#40;FIS <span class="elsevierStyleGrantNumber" refid="gs0005">PI10&#47;01538</span> and <span class="elsevierStyleGrantNumber" refid="gs0005">PI13&#47;02011</span>&#41; and <span class="elsevierStyleGrantSponsor" id="gs0010">Beca SEPAR</span><span class="elsevierStyleGrantNumber" refid="gs0010">264&#47;2012</span>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The funding agency had no role in study design&#44; in collection&#44; analysis or interpretation of data&#59; in writing of the manuscript&#59; or in the decision to submit the paper for publication&#46; The content is solely the responsibility of the authors and does not necessarily represent the official views of the Institute of Health Carlos III &#40;ISC III&#41; and SEPAR from Spain&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To compare oxygen saturation index &#40;rSO<span class="elsevierStyleInf">2</span>&#41; obtained simultaneously in two different brachial muscles&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Prospective and observational study&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Setting</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Intensive care unit&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Patients</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Critically ill patients with community-acquired pneumonia&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Interventions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Two probes of NIRS device &#40;INVOS 5100&#41; were simultaneously placed on the brachioradialis &#40;BR&#41; and deltoid &#40;D&#41; muscles&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Variables</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">rSO<span class="elsevierStyleInf">2</span> measurements were recorded at baseline &#40;ICU admission&#41; and at 24<span class="elsevierStyleHsp" style=""></span>h&#46; Demographic and clinical variables were registered&#46; Pearson&#39;s correlation coefficient was used to assess the association between continuous variables&#46; The consistency of the correlation was assessed using the intraclass correlation coefficient &#40;ICC&#41; and Bland&#8211;Altman plot&#46; The predictive value of the rSO<span class="elsevierStyleInf">2</span> for mortality was calculated by ROC curve&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Nineteen patients were included with an ICU mortality of 21&#46;1&#37;&#46; The rSO<span class="elsevierStyleInf">2</span> values at baseline and at 24<span class="elsevierStyleHsp" style=""></span>h were significantly higher in D than in BR muscle&#46; Values obtained simultaneously in both limbs showed a strong correlation and adequate consistency&#58; BR &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;95&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#59; ICC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;94&#59; 95&#37; CI&#58; 0&#46;90&#8211;0&#46;96&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; D &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;88&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#59; ICC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;88&#59; 95&#37; CI&#58; 0&#46;80&#8211;0&#46;90&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; but a wide limit of agreement&#46; Non-survivors had rSO<span class="elsevierStyleInf">2</span> values significantly lower than survivors at all times of the study&#46; No patient with rSO<span class="elsevierStyleInf">2</span> &#62;60&#37; in BR died&#44; and only 17&#46;6&#37; died with an rSO<span class="elsevierStyleInf">2</span> value &#62;60&#37; in D&#46; Both muscles showed consistent discriminatory power for mortality&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Both BR and D muscles were appropriate for measuring rSO<span class="elsevierStyleInf">2</span>&#46;</p></span>"
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        "resumen" => "<span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Objetivo</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Comparar el &#237;ndice de saturaci&#243;n tisular de ox&#237;geno &#40;rSO<span class="elsevierStyleInf">2</span>&#41; medido de forma simult&#225;nea en 2 diferentes m&#250;sculos braquiales&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Dise&#241;o</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo&#44; observacional&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">&#193;mbito</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Servicio de Medicina Intensiva&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pacientes</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Cr&#237;ticos con neumon&#237;a comunitaria&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Intervenciones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Dos sensores con tecnolog&#237;a NIRS &#40;INVOS&#8482; 5100&#41; fueron ubicados de forma simult&#225;nea en los m&#250;sculos braquiorradial &#40;BR&#41; y deltoides &#40;D&#41;&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Variables</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Las mediciones del rSO<span class="elsevierStyleInf">2</span> se efectuaron al ingreso &#40;basal&#41; y a las 24<span class="elsevierStyleHsp" style=""></span>h&#46; Se registraron los datos demogr&#225;ficos y cl&#237;nicos&#46; La correlaci&#243;n de Pearson se utiliz&#243; para estudiar la asociaci&#243;n entre variables continuas&#46; La concordancia de la correlaci&#243;n fue valorada mediante el coeficiente de correlaci&#243;n intraclase &#40;ICC&#41; y el an&#225;lisis de Bland-Altman&#46; El valor predictivo de rSO<span class="elsevierStyleInf">2</span> para mortalidad fue calculado mediante curva ROC&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 19 pacientes con una mortalidad de 21&#44;1&#37;&#46; El valor basal y a las 24<span class="elsevierStyleHsp" style=""></span>h de rSO<span class="elsevierStyleInf">2</span> fue significativamente mayor en D respecto del BR&#46; Los valores obtenidos de forma simult&#225;nea en ambos miembros evidenciaron una buena correlaci&#243;n y una adecuada concordancia&#58; BR &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;95&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#46; ICC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;94&#59; IC 95&#37;&#58; 0&#44;90-0&#44;96&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; D &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;88&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#46; ICC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;88&#59; IC 95&#37;&#58; 0&#44;80-0&#44;90&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; as&#237; como un amplio rango de concordancia&#46; Los fallecidos presentaron valores de rSO<span class="elsevierStyleInf">2</span> significativamente menores que los supervivientes en todos los momentos del estudio&#46; Ning&#250;n paciente con rSO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>60&#37; en BR falleci&#243;&#44; y solo el 17&#44;6&#37; fallecieron con un rSO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>60&#37; en D&#46; Ambos m&#250;sculos evidenciaron un buen poder de discriminaci&#243;n para mortalidad&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Tanto el m&#250;sculo BR como el D fueron apropiados para la medici&#243;n del rSO<span class="elsevierStyleInf">2</span>&#46;</p></span>"
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Area Under Receiver Operating Characteristic &#40;AUROC&#41; curves for skeletal muscle rSO<span class="elsevierStyleInf">2</span> in brachioradialis and deltoid muscle at ICU admission &#40;baseline&#41; and at 24<span class="elsevierStyleHsp" style=""></span>h for mortality&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">SD&#58; standard deviation&#59; APACHE II&#58; Acute Physiologic Physiology and Chronic Health Evaluation II&#59; ICU&#58; intensive care unit&#59; SOFA&#58; sequential organ failure assessment&#59; SAPS 3&#58; Simplified Acute Physiology Score 3&#59; NA&#58; not applicable&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">All patients &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Survivors &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Non-survivors &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-Value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Age &#40;yr&#41;&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&#46;0 &#40;16&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">52&#46;9 &#40;17&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&#46;0 &#40;14&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Men&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;73&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 &#40;80&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;50&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">APACHE II score at day-1&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;6 &#40;6&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#46;2 &#40;3&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&#46;0 &#40;10&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">SAPS 3 score at day-1&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">52&#46;2 &#40;7&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">51&#46;1 &#40;6&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56&#46;0 &#40;9&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">SOFA at day-1&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;2 &#40;1&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;9 &#40;1&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;0 &#40;3&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">ICU length of stay &#40;days&#41;&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;6 &#40;13&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;6 &#40;10&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#46;1 &#40;23&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Mechanical ventilation at day-1&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;47&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 &#40;33&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Shock at day-1&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;47&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 &#40;33&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">ICU mortality rate&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;21&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1430517.png"
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Baseline characteristic of the 19 patients with respiratory sepsis included in the study&#46;</p>"
        ]
      ]
      7 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">rSO<span class="elsevierStyleInf">2</span> values are shown as mean and standard deviation&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Survivors</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Non-survivors</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">rSO<span class="elsevierStyleInf">2</span> brchioradialis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">rSO<span class="elsevierStyleInf">2</span> deltoid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">rSO<span class="elsevierStyleInf">2</span> brachioradialis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">rSO<span class="elsevierStyleInf">2</span> deltoid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">ICU admission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">66&#46;9 &#40;8&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70&#46;3 &#40;6&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&#46;7 &#40;3&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60&#46;6 &#40;6&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&#46;3 &#40;8&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73&#46;5 &#40;8&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&#46;4 &#40;5&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">56&#46;2 &#40;5&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1430518.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">Skeletal regional saturation index &#40;rSO<span class="elsevierStyleInf">2</span>&#41; in brachioradialis and deltoid muscle at ICU admission and at 24<span class="elsevierStyleHsp" style=""></span>h in survivors and non-survivors&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:28 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The prognostic value of muscle StO<span class="elsevierStyleInf">2</span> in septic patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46; Creteur"
                            1 => "T&#46; Carollo"
                            2 => "G&#46; Soldati"
                            3 => "G&#46; Buchele"
                            4 => "D&#46; De Backer"
                            5 => "J&#46;L&#46; Vincent"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00134-007-0739-3"
                      "Revista" => array:6 [
                        "tituloSerie" => "Intensive Care Med"
                        "fecha" => "2007"
                        "volumen" => "33"
                        "paginaInicial" => "1549"
                        "paginaFinal" => "1556"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17572876"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Continuous muscle tissue oxygenation in critically injured patients&#46; A prospective observational study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46;G&#46; Ikossi"
                            1 => "M&#46;M&#46; Knudson"
                            2 => "D&#46;J&#46; Morabito"
                            3 => "M&#46;J&#46; Cohen"
                            4 => "J&#46;J&#46; Wan"
                            5 => "L&#46; Khaw"
                          ]
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                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.ta.0000239500.71419.58"
                      "Revista" => array:6 [
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                        "fecha" => "2006"
                        "volumen" => "61"
                        "paginaInicial" => "780"
                        "paginaFinal" => "790"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17033541"
                            "web" => "Medline"
                          ]
                        ]
                      ]
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              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mortality and regional oxygen saturation index in septic shock patients&#58; a pilot study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Rodr&#237;guez"
                            1 => "T&#46; Lisboa"
                            2 => "I&#46; Mart&#237;n-Loeches"
                            3 => "E&#46; D&#237;az"
                            4 => "S&#46; Trefler"
                            5 => "M&#46;I&#46; Restrepo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/TA.0b013e318216f72c"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Trauma"
                        "fecha" => "2011"
                        "volumen" => "70"
                        "paginaInicial" => "1145"
                        "paginaFinal" => "1152"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21610429"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Near-infrared spectroscopy as an index of brain and tissue oxygenation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "J&#46;M&#46; Murkin"
                            1 => "M&#46; Arango"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/bja/aep299"
                      "Revista" => array:7 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2009"
                        "volumen" => "103"
                        "numero" => "Suppl&#46; 1"
                        "paginaInicial" => "i3"
                        "paginaFinal" => "i13"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20007987"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Characterization of tissue oxygen saturation and vascular occlusion test&#58; influence of measurement sites&#44; probe sizes and deflation thresholds"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46; Gomez"
                            1 => "J&#46; Mesquida"
                            2 => "P&#46; Simon"
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