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        "titulo" => "Impacto de los componentes del s&#237;ndrome poscuidados intensivos del paciente en la sobrecarga de los cuidadores"
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          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Flow chart of patient and caregiver enrolment &#40;in attachment&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Nowadays an increasing number of patients survive critical illness after the tremendous advances in medical science and healthcare&#46; Although survival is clearly an important and crucial outcome&#44; the clinical condition after survival is also fundamental&#46; Post Intensive Care Syndrome &#40;PICS&#41; is a multidimensional problem experienced after an Intensive Care Unit &#40;ICU&#41; stay&#44; which can persist for several years&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">1</span></a> PICS is described both for the patient &#40;PICS-P&#41; and their family &#40;PICS-F&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">1&#8211;4&#44;6&#44;7</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">PICS-P includes non-physical components like anxiety&#44; depression&#44; post-traumatic stress disorder and cognitive impairment and physical problems like ICU acquired weakness&#44; mobility impairment&#44; glottis dysfunction&#44; pain or pulmonary function impairment&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">2</span></a> The real prevalence of PICS among ICU survivors is still unknown&#44; with some studies reporting an incidence as high as 73&#37; at hospital discharge and 46&#37; one year after ICU&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The National Institute for Health and Care Excellence published guidelines for managing rehabilitation after critical care and have proposed a care pathway for these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">5</span></a> In a first stage&#44; at ICU admission patients at risk should be identified&#46; Risk factors for PICS-P are based both on patient background and acute illness features&#46; Previous mobility&#44; respiratory or cognitive impairments&#44; long expected ICU stay&#44; physical or neurological injury&#44; acute physical impairment and severe respiratory failure are risk factors for physical PICS components&#46; On the other hand&#44; risk factors for psychological PICS are previous psychiatric disorder&#44; dementia or story at ICU of nightmares&#44; intrusive memories&#44; anxiety&#44; recurrent panic attacks and refusing to talk about the disease&#46; On a second stage&#44; PICS components should be identified before ICU discharge and rehabilitation should be started as soon as possible&#46; After discharge&#44; a follow-up team should accompany the patient during ward based-care focused on rehabilitation goals and a revaluation should be made before discharge to home or community&#46; In a fourth stage&#44; the patient should be revaluated 2 to 3 months after critical care&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Although most of the studies done after ICU care are focused in the patient despite the recognition that they are not the only ones affected by ICU stay&#46; Caregivers play a crucial role in patients&#8217; recovery and they face themselves many stressors like fearfulness&#44; disruption of family dynamics&#44; financial pressure and work overload&#44; all of which can contribute to caregiver burden&#46; In the light of this knowledge PICS has also been recognized for caregivers&#44; particularly families &#40;PICS-F&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">6&#44;7</span></a> Extensive burdens are described for families following the patient&#39;s ICU admission&#44; related mostly with psychosocial issues&#44; quality of life&#44; lifestyle&#44; employment and financial status&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Even though there is an increasing awareness of the importance of psychological impairments and burden is common in caregivers&#44; more studies are needed to relate patient status after discharge &#40;PICS-P&#41; and PICS-F in a way that will allow the ICU teams to intervene and prevent or treat it&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">This study aims to determine the incidence of patient&#39;s post-intensive care syndrome &#40;PICS-P&#41; and caregiver&#39;s burden 3 months after Intensive Care Unit &#40;ICU&#41; discharge and determine the impact of different components of PICS-P on caregiver&#39;s burden&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Patients and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">A prospective study was conducted over a 26-month period&#44; between January 2013 and February 2015 in a mixed surgical-medical adult ICU and the Follow-up Clinic&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Hospital</span><p id="par0040" class="elsevierStylePara elsevierViewall">Hospital Pedro Hispano has an open model&#44; mixed surgical-medical intensive care unit with 8 beds and approximately 300 admissions per year&#46; The ICU outreach team has different components with a Medical Emergency Team and a Follow-up Team&#46; The Follow-up Team is responsible for the assessment of patients during all hospital stay after ICU&#44; in particularly at three moments&#58; first week&#44; 1 month after ICU or at the hospital discharge and 3 months after discharge from ICU in a Follow-up Clinic&#46; A nurse and a physician make up the Follow-up Team&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Patients assessment and patient&#39;s post-intensive care syndrome</span><p id="par0045" class="elsevierStylePara elsevierViewall">All surviving patients who stayed at ICU for at least two days were included along with their family&#46; Patient characteristics&#44; severity of illness &#40;measured with SAPS II at first 24<span class="elsevierStyleHsp" style=""></span>h&#41;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">9</span></a> and length of ICU stay were collected&#46; Risk for PICS was assessed at admission based on described risk factors and patients with at least one risk factor were considered as at risk&#46; All patients&#44; both considered as at risk or not&#44; were assessed for PICS at different moments namely at ICU discharge&#44; at their first week in ward&#44; at 1 month after or hospital discharge and at 3 months after discharge&#46; Three months after ICU stay patients were invited to attend the Follow-up Clinic for revaluation and PICS assessment&#46; In all moments patients were evaluated for both physical and non-physical PICS&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Physical components &#40;mobility impairment&#44; ICU-acquired weakness&#41; were clinically evaluated and the &#8220;Medical Research Council Scale for Muscle Strength&#8221; was used&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> A score &#8804;4 was considered for a decreased muscle strength and if present in at least two muscular groups was coded as ICU acquired weakness&#46; As for the psychological components &#40;anxiety&#44; depression&#44; post-traumatic stress disorder&#41;&#44; the questionnaires &#8220;Hospital Anxiety and Depression Scale&#8221; &#40;HADS&#41;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a> and &#8220;Post-Traumatic Stress Syndrome 14 Questions Inventory&#8221; &#40;PTSS-14&#41;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">12</span></a> were applied&#46; For Anxiety and Depression subscales&#44; a HADS &#62;10 was considered positive to the mood disorder and a HADS between 8 and 10 as being suggestive of the presence of the respective state &#40;the authors used the number ten as cut-off decision&#41;&#46; A PTSS &#8805;49 was considered positive to post-traumatic stress disorder risk&#46; Before 3 months&#8217; assessment&#44; questionnaires were sent by mail in advance&#46; In all moments patients received the questionnaires in advance and were able to answer then alone and quietly&#46; For the purpose of this study only data on PICS-P at 3 months after ICU discharge was analyzed&#44; independently how much time passed over the date of hospital discharge&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Caregivers assessment and caregiver&#39;s burden</span><p id="par0055" class="elsevierStylePara elsevierViewall">Caregiver was defined as the individual who provided the majority of support for the patient&#46; No cohabitation or legal relation with the patient was required&#46; Caregiver eligibility criteria included&#58; being a non-paid caregiver&#44; able to read and speak Portuguese and accept to participate in the study&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Caregivers were invited to the Patients&#8217; Follow-up Clinic to assess burden 3 months after the patient discharge and were evaluated in the same day as the patient&#46; Family burden was assessed using the &#8220;Zarit Burden Interview&#8221; which is a self-response questionnaire designed to expose the issues experienced by caregivers&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">13&#8211;16</span></a> Caregivers were asked to respond to a series of 22 questions about the impact of the patients&#8217; disabilities on their life&#46; For each item&#44; caregivers indicate how often they felt that specific burden &#40;never<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44; rarely<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44; sometimes<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#44; quite frequently<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#44; or nearly always<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41;&#46; Higher scores indicate greater caregiver distress&#46; As previously described by Zarit&#44; caregivers were classified as without overburden if the Zarit result was less than or equal to 21&#44; with low overburden if they reach a score between 22 and 40&#44; or with high overburden if they have a score of at least 41&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">17</span></a> The questionnaire was sent in advance by mail to all caregivers which allowed them to answered it quietly and lonely at home and then bring it to the Follow-up Clinic&#46; Caregiver&#39;s burden was assessed only at 3 months after patient&#39;s ICU discharge&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Ethical aspects</span><p id="par0065" class="elsevierStylePara elsevierViewall">It was a purely observational study without any implication in patients or caregivers&#8217; treatment&#46; All questionnaires&#44; both for patients and caregivers&#44; were preceded by an introduction where it was explained the purpose of the questionnaire and that it would be used in a scientific observational study&#46; Informed consent was waved&#46; Patients and caregivers voluntarily answered the questionnaires and confidentiality was maintained&#46; This study has been assessed and approved by the Institutional Ethics Committee&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Statistical analysis</span><p id="par0070" class="elsevierStylePara elsevierViewall">The relationship between caregiver&#39;s burden and the presence of different components of patient&#39;s PICS&#44; patient characteristics&#44; severity of illness and length of ICU stay were also analyzed&#46; Categorical variables were described through absolute &#40;<span class="elsevierStyleItalic">n</span>&#41; and relative &#40;&#37;&#41; frequencies&#44; and continuous variables were described as mean and standard deviation&#44; median&#44; percentiles&#44; and minimum and maximum when appropriate&#46; Hypotheses were tested regarding the distribution of continuous variables with non-normal distribution by using the non-parametric Mann&#8211;Whitney and Kruskal&#8211;Wallis tests&#44; depending on the nature of the hypothesis&#46; For categorical variables&#44; a Chi-square test or a Fisher&#39;s exact test was used&#44; as appropriate&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">All the reported <span class="elsevierStyleItalic">p</span>-values were two-sided&#44; and <span class="elsevierStyleItalic">p</span>-values of &#60;0&#46;05 were considered statistically significant&#46; All data were arranged&#44; processed and analyzed with SPSS&#174; v&#46;23&#46;0 &#40;Statistical Package for Social Sciences&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Patient&#39;s post-intensive care syndrome 3 months after ICU discharge</span><p id="par0080" class="elsevierStylePara elsevierViewall">During the study period 636 patients were admitted to ICU&#46; The most frequent admission motives were&#58; septic shock&#44; respiratory failure and post-major surgery&#46; The mortality rate was 19&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>120&#41;&#46; From surviving patients&#44; 161 were excluded from the study as they stayed less than 48<span class="elsevierStyleHsp" style=""></span>h at the ICU&#46; A total of 355 met the criteria to be followed by the Follow-up team and 245 were evaluated in the Follow-up Clinic 3 months after &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Fifty-seven patients died between ICU discharge and consultation and another 53 missed the clinic for different reasons&#46; Patient characteristics at 3 months Follow-up Clinic are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Three months after their ICU stay&#44; 106 patients &#40;43&#37;&#41; reported at least one component of PICS&#58; 20&#37; had depression&#44; 19&#37; anxiety&#44; 11&#37; post-traumatic stress disorder&#44; 11&#37; mobility impairment and 20&#37; ICU acquired weakness&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Caregivers&#8217; burden</span><p id="par0090" class="elsevierStylePara elsevierViewall">Over the study period&#44; 168 caregivers completed the survey&#44; with a response rate of 69&#37; as 77 patients failed to have their caregiver evaluated &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Exactly 50&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>84&#41; of the caregivers reported no overburden&#44; 34&#46;5&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>58&#41; experienced low overburden and 15&#46;5&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>26&#41; felt moderate to high overburden&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Impact of patient&#39;s PICS on caregiver&#39;s burden</span><p id="par0095" class="elsevierStylePara elsevierViewall">Impact of patient&#39;s PICS on caregiver&#39;s burden was finally analyzed on a sample of 168 patients and caregivers &#40;paired&#41;&#46; From this group&#44; two patients sent their answered questionnaires to the clinic but failed to be present there&#44; so they were not evaluated for physical limitations&#46; For that reason&#44; for comparison between caregivers and physical PICS only 166 pairs were considered&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Patient&#39;s anxiety and depression at 3 months &#40;median HADS of 12 for anxiety and Median HADS of 9 for depression&#41; has a statically significant association with higher degrees of caregiver&#39;s overburden &#40;Zarit &#8805; 41&#41;&#46; Physical components of patients&#8217; PICS at 3 months failed to show influence on caregivers&#8217; burden&#46; There were no differences in caregivers&#8217; burden regarding patients gender&#44; age&#44; SAPS II and ICU length of stay &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">The main finding of this study is that the presence of psychological components of Post Intensive Care Syndrome 3 months after ICU seems to influence negatively the overburden of caregivers&#46; On the other hand&#44; physical problems failed to show important impact in caregivers&#8217; overburden&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">As far as we know&#44; no study directly related the different components of PICS-P at 3 months with caregiver&#39;s burden at this same time&#46; We believe that our findings show an important relation between them that might help defining a strategy to identify and deal with caregivers at risk&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Several articles show that family members of critically ill patients are at risk for anxiety and depressive conditions&#44; and the combination of this is known as PICS-F&#44; though there is disagreement on what the term &#8220;caregiver burden&#8221; means&#46; A recent review from Van Beusekom et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">8</span></a> analyses the usual reported burden and the tools used to measure it&#46; It is discussed that caregivers have extensive burdens&#44; from changes in psychological status&#44; employment and lifestyle to decreased quality of life&#46; This review paper reported caregivers&#8217; burden prevalence between 16&#37; and 90&#37; during ICU or hospital stay&#44; between 12&#46;2&#37; and 26&#46;2&#37; at 3 months&#44; 4&#46;7&#37; and 36&#46;4&#37; at 6 months and between 22&#46;8&#37; and 44&#37; at 12 months after ICU discharge&#46; In our population&#44; the prevalence of patients&#8217; PICS is consistent with this and other studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Caring and dealing with an acutely ill loved one can be stressful and difficult to handle&#46; The psychological recovery of the family has tended to be forgotten and high rates of anxiety&#44; depression and Post-Traumatic Stress Disorder have been reported in caregivers&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">18</span></a> PICS-F and caregiver&#39;s burden should be assessed so caregivers can receive professional care if necessary&#46; It&#39;s not clear what is the best method for their assessment and several scales were used&#44; like Zarit Burden Interview&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">13</span></a> Hospital Anxiety and Depression Scale subscale<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a> or &#8220;Post-Traumatic Stress Syndrome 14 Questions Inventory &#40;PTSS-14&#41;&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">12</span></a> In this study&#44; Zarit Burden Interview was used because it&#39;s a simple self-answering questionnaire already translated&#44; used and validated in the Portuguese population&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">16</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Identifying predictors of adverse caregivers&#8217; outcome is fundamental for targeting intervention strategies&#46; Previous identified caregiver&#39;s risk factors for PICS-F are female gender&#44; younger relative&#44; being a spouse&#44; older patients age&#44; more chronic conditions&#44; lifestyle interference&#44; lower mastery and overload&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">6&#44;19</span></a> In our study patient gender&#44; age&#44; severity of illness and length of ICU stay also failed to show influence on caregiver&#39;s burden&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Few studies have evaluated patient specific predictors of caregivers&#8217; burden or PICS-F&#46; Some studies try to relate physical and functional PICS-P with caregiver burden with inconsistent results&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">13&#44;20&#8211;23</span></a> Swoboda et al&#46; found a relation between caregiver burden using a family impact survey and patient functional status using the Sickness Impact Profile&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">21</span></a> Choi et al&#46; finds a relation between caregiver burden using the Zarit interview and patient functional status using the Activities of Daily Living&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">20</span></a> All the studies show a small sample size in a single centre with important selection bias&#46; However other studies fail to find a significant relation between the family burden and the physical patient status<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">20&#44;22&#44;23</span></a> and are in accordance with our findings&#46; Notably Van Pelt et al&#46; finds a lack of relation between caregiver burden using the Centre for Epidemiologic Studies Depression and patient functional status using the Activities of Daily Living in their ICU cohort patients&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">22</span></a> Also in accordance with our study&#44; Choi et al&#46; show that remains high even caregiver distress if the patient regains pre-admission functional status&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">20</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Regarding studies that relate psychological PICS-P with caregiver burden&#58; we&#8217;ve only found one paper from Cameron et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">24</span></a> and this study is in line with ours&#46; They found that caregiver emotional distress was higher when the ARDS survivors reported more depressive symptoms&#46; The survivors&#8217; functional status&#44; expressed as the distance walked in 6<span class="elsevierStyleHsp" style=""></span>min&#44; was not associated with the informal caregiver emotional stress&#44; also in accordance with what we found&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Both previous studies and ours suggest that it is easier for relatives to accept and adapt to physical limitations than to deal with a psychologically wounded patient&#46; More studies are needed to understand caregiver role and burden in the care of ICU patients&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">This study has some limitations that have to be pointed out&#46; It is a single-centre study with a small sample that may be insufficient to extrapolate results onto the general population&#46; Furthermore&#44; the questionnaire was self-reported but not anonymous as mail was sent to the ICU patient&#44; so caregivers may have been afraid to be judged by their relatives or professionals for their answers&#46; More importantly we did not collect data on the caregiver characteristics that we could relate to its burden&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Additionally&#44; the responses of the 31&#37; of the caregivers who did not participate in the study could have a significant impact on the conclusions drawn&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In conclusion&#44; the caregiver&#39;s role is frequently under-looked by professionals&#44; but is nonetheless essential in the patient&#39;s recovery&#46; Our study shows that post ICU patient anxiety and depression play an important role in the burden of caregivers&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Identification of PICS-P is fundamental not only to define an early strategy for patients but also to prevent overburden and PICS-F in caregivers&#46; A structured multidisciplinary approach is crucial and should be designed to identify&#44; support and help caregivers at risk&#46; A more comprehensive study is required to better understand the connections between different components of PICS-P and PICS-F&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Funding</span><p id="par0165" class="elsevierStylePara elsevierViewall">None&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Contribution of the authors</span><p id="par0170" class="elsevierStylePara elsevierViewall">JT&#44; DC&#44; EM&#44; CV&#44; AF&#44; RA and EG designed the study and managed data collection&#46; Analysis and interpretation of data was undertaken by CCD&#46; JT and EG wrote the first manuscript draft and were responsible for subsequent collation of inputs and redrafting&#46; DC&#44; EM and RA helped to revise the manuscript&#46; All authors read and approved the final manuscript&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Conflict of interests</span><p id="par0175" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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              "titulo" => "Hospital"
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            1 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Patients assessment and patient&#39;s post-intensive care syndrome"
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              "identificador" => "sec0020"
              "titulo" => "Caregivers assessment and caregiver&#39;s burden"
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              "titulo" => "Ethical aspects"
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          "titulo" => "Results"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Patient&#39;s post-intensive care syndrome 3 months after ICU discharge"
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              "identificador" => "sec0045"
              "titulo" => "Caregivers&#8217; burden"
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              "titulo" => "Impact of patient&#39;s PICS on caregiver&#39;s burden"
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    "fechaRecibido" => "2016-08-18"
    "fechaAceptado" => "2016-12-03"
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        0 => array:4 [
          "clase" => "keyword"
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            0 => "Caregivers"
            1 => "Burden"
            2 => "Post-intensive care syndrome"
            3 => "Critical care"
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          "palabras" => array:4 [
            0 => "Cuidadores"
            1 => "Sobrecarga"
            2 => "S&#237;ndrome poscuidados intensivos"
            3 => "Cuidados intensivos"
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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 evaluate patient post-intensive care syndrome &#40;PICS-P&#41; and caregiver burden 3 months after discharge from the Intensive Care Unit &#40;ICU&#41; and determine the impact of different components of PICS-P upon caregiver burden&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A prospective observational study was conducted over 26 months &#40;January 2013&#8211;February 2015&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Setting</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Medical-surgical ICU and follow-up consultation in Portugal&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Patients or participants</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Patients discharged after a minimum of 2 days in the ICU&#46; Caregiver inclusion criteria&#58; not paid&#44; written and spoken Portuguese&#44; and agreement to participate in the study&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Main variables of interest</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">In ICU&#58; Patient gender&#44; age&#44; severity of illness &#40;SAPS II&#41; and length of ICU stay&#46; At 3 months caregiver burden&#44; physical &#40;reduced mobility&#44; weakness acquired in the ICU&#41; and psychological components of PICS &#40;anxiety&#44; depression&#44; post-traumatic stress disorder&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A total of 168 caregivers completed the survey &#40;response rate of 69&#37;&#41;&#46; A low degree of overburden was reported by 34&#46;5&#37; of caregivers&#44; while 15&#46;5&#37; showed moderate to high levels of overburden&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Patient anxiety and depression 3 months after ICU discharge significantly influenced the presence of caregiver burden &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;030 vs <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;008&#41;&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">When physical components of PICS-P were evaluated&#44; no influence on caregiver burden was observed&#46; Patient demographics&#44; severity of illness and length of stay also failed to influence caregiver burden&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The presence of psychological components of PICS-P 3 months after ICU seems to have a negative impact upon caregiver burden&#46; On the other hand&#44; physical problems showed no important impact upon caregiver overburden&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Objetivo</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Caracterizar el s&#237;ndrome poscuidados intensivos de los pacientes &#40;PICS-P&#41; y la sobrecarga de los cuidadores a los 3 meses del alta de la Unidad de Cuidados Intensivos &#40;UCI&#41;&#46; Averiguar c&#243;mo la sobrecarga es influida por los diferentes componentes del PICS-P&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Dise&#241;o</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo observacional de 26 meses &#40;enero de 2013-febrero de 2015&#41;&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">&#193;mbito</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">UCI m&#233;dico-quir&#250;rgica y consulta de seguimiento en Portugal&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Pacientes o participantes</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Pacientes dados de alta despu&#233;s de 2 o m&#225;s d&#237;as en la UCI&#46; Criterios de inclusi&#243;n de los cuidadores&#58; no cobrar&#44; leer y hablar portugu&#233;s y aceptar participar en el estudio&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Principales variables de inter&#233;s</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">En la UCI&#58; g&#233;nero&#44; edad&#44; gravedad de la enfermedad &#40;SAPS II&#41; y estancia en la UCI&#46; A los 3 meses&#58; sobrecarga del cuidador&#59; componentes f&#237;sicos &#40;reducci&#243;n de la movilidad&#44; debilidad adquirida en la UCI&#41; y ps&#237;quicos &#40;ansiedad&#44; depresi&#243;n&#44; s&#237;ndrome de estr&#233;s postraum&#225;tico&#41; del PICS-P&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Un total de 168 cuidadores respondieron al cuestionario de sobrecarga &#40;tasa de respuesta del 69&#37;&#41;&#46; El nivel de sobrecarga era bajo en el 34&#44;5&#37; de los casos y moderado a alto en el 15&#44;5&#37;&#46; A los 3 meses&#44; la presencia de ansiedad y depresi&#243;n en los pacientes influy&#243; de forma significativa en la sobrecarga de los cuidadores &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;030 y p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;008&#44; respectivamente&#41;&#46; No se encontr&#243; ninguna influencia de los componentes f&#237;sicos del PICS-P&#44; la edad&#44; el g&#233;nero&#44; el SAPS II o la estancia en UCI sobre la sobrecarga&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">La presencia de componentes psicol&#243;gicos de PICS-P a los tres meses parece influir de forma negativa en el nivel de sobrecarga de los cuidadores&#46; Los problemas f&#237;sicos parecen no tener impacto sobre dicha sobrecarga&#46;</p></span>"
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; <span class="elsevierStyleItalic">n</span>&#44; number&#59; Min&#44; Minimum&#59; Max&#44; Maximum&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Patient Age&#44; median &#40;min-max&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">61 years &#40;15&#8211;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Patient sex&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">162 &#40;66&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">83 &#40;34&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">SAPS II&#44; median &#40;min-max&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45 &#40;15&#8211;72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">ICU stay&#44; median &#40;min-max&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 days &#40;2&#8211;110&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Days of sedation&#44; median &#40;min-max&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 day &#40;0&#8211;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Days of mechanical ventilation&#44; median &#40;min-max&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 days &#40;0&#8211;58&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "leyenda" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; <span class="elsevierStyleItalic">n</span>&#44; number&#59; Min&#44; minimum&#59; Max&#44; Maximum&#59; HADS&#44; Hospital Anxiety and Depression Scale&#59; PTSS 14&#44; Post-Traumatic Stress Syndrome 14 Questions Inventory&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No overburden<br>&#40;Zarit &#8804; 21&#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">Low overburden &#40;Zarit 22&#8211;40&#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">Moderate to High overburden &#40;Zarit &#8805; 41&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Patient gender&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26 &#40;31&#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">20 &#40;34&#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;35&#37;&#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;885&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58 &#40;69&#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">38 &#40;66&#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">17 &#40;65&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Patient Age&#44; median &#40;min-max&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60 &#40;16&#8211;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67 &#40;20&#8211;82&#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 &#40;26&#8211;83&#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;108&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">SAPS II&#44; median &#40;min-max&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37 &#40;11&#8211;72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41 &#40;2&#8211;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33 &#40;5&#8211;72&#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;169&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Days in ICU stay median &#40;min-max&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;2&#8211;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;2&#8211;110&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;5&#8211;26&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;720&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">0&#46;030</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&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">6 &#40;0&#8211;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;0&#8211;16&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">PTSS 14&#44; median &#40;min-max&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27 &#40;14&#8211;83&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;178<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Association between patients&#8217; PICS and caregivers&#8217; burden 3 months after ICU&#46;</p>"
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      "seccion" => array:1 [
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Original article
The impact of the patient post-intensive care syndrome components upon caregiver burden
Impacto de los componentes del síndrome poscuidados intensivos del paciente en la sobrecarga de los cuidadores
J. Torresa,
Autor para correspondencia
joanavtorres@gmail.com

Corresponding author.
, D. Carvalhoa, E. Molinosa, C. Valesa, A. Ferreiraa, C.C. Diasb,c, R. Araújoa, E. Gomesa
a Intensive Care Unit, Hospital Pedro Hispano, Unidade Local de Saúde de Matosinhos, Rua Dr. Eduardo Torres, 4464-513 Matosinhos, Portugal
b CIDES - Department of Health Information and Decision Sciences, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
c CINTESIS - Centre for Health Technology and Services Research, Porto, Portugal
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mobility impairment&#44; glottis dysfunction&#44; pain or pulmonary function impairment&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">2</span></a> The real prevalence of PICS among ICU survivors is still unknown&#44; with some studies reporting an incidence as high as 73&#37; at hospital discharge and 46&#37; one year after ICU&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The National Institute for Health and Care Excellence published guidelines for managing rehabilitation after critical care and have proposed a care pathway for these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">5</span></a> In a first stage&#44; at ICU admission patients at risk should be identified&#46; Risk factors for PICS-P are based both on patient background and acute illness features&#46; Previous mobility&#44; respiratory or cognitive impairments&#44; long expected ICU stay&#44; physical or neurological injury&#44; acute physical impairment and severe respiratory failure are risk factors for physical PICS components&#46; On the other hand&#44; risk factors for psychological PICS are previous psychiatric disorder&#44; dementia or story at ICU of nightmares&#44; intrusive memories&#44; anxiety&#44; recurrent panic attacks and refusing to talk about the disease&#46; On a second stage&#44; PICS components should be identified before ICU discharge and rehabilitation should be started as soon as possible&#46; After discharge&#44; a follow-up team should accompany the patient during ward based-care focused on rehabilitation goals and a revaluation should be made before discharge to home or community&#46; In a fourth stage&#44; the patient should be revaluated 2 to 3 months after critical care&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Although most of the studies done after ICU care are focused in the patient despite the recognition that they are not the only ones affected by ICU stay&#46; Caregivers play a crucial role in patients&#8217; recovery and they face themselves many stressors like fearfulness&#44; disruption of family dynamics&#44; financial pressure and work overload&#44; all of which can contribute to caregiver burden&#46; In the light of this knowledge PICS has also been recognized for caregivers&#44; particularly families &#40;PICS-F&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">6&#44;7</span></a> Extensive burdens are described for families following the patient&#39;s ICU admission&#44; related mostly with psychosocial issues&#44; quality of life&#44; lifestyle&#44; employment and financial status&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Even though there is an increasing awareness of the importance of psychological impairments and burden is common in caregivers&#44; more studies are needed to relate patient status after discharge &#40;PICS-P&#41; and PICS-F in a way that will allow the ICU teams to intervene and prevent or treat it&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">This study aims to determine the incidence of patient&#39;s post-intensive care syndrome &#40;PICS-P&#41; and caregiver&#39;s burden 3 months after Intensive Care Unit &#40;ICU&#41; discharge and determine the impact of different components of PICS-P on caregiver&#39;s burden&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Patients and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">A prospective study was conducted over a 26-month period&#44; between January 2013 and February 2015 in a mixed surgical-medical adult ICU and the Follow-up Clinic&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Hospital</span><p id="par0040" class="elsevierStylePara elsevierViewall">Hospital Pedro Hispano has an open model&#44; mixed surgical-medical intensive care unit with 8 beds and approximately 300 admissions per year&#46; The ICU outreach team has different components with a Medical Emergency Team and a Follow-up Team&#46; The Follow-up Team is responsible for the assessment of patients during all hospital stay after ICU&#44; in particularly at three moments&#58; first week&#44; 1 month after ICU or at the hospital discharge and 3 months after discharge from ICU in a Follow-up Clinic&#46; A nurse and a physician make up the Follow-up Team&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Patients assessment and patient&#39;s post-intensive care syndrome</span><p id="par0045" class="elsevierStylePara elsevierViewall">All surviving patients who stayed at ICU for at least two days were included along with their family&#46; Patient characteristics&#44; severity of illness &#40;measured with SAPS II at first 24<span class="elsevierStyleHsp" style=""></span>h&#41;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">9</span></a> and length of ICU stay were collected&#46; Risk for PICS was assessed at admission based on described risk factors and patients with at least one risk factor were considered as at risk&#46; All patients&#44; both considered as at risk or not&#44; were assessed for PICS at different moments namely at ICU discharge&#44; at their first week in ward&#44; at 1 month after or hospital discharge and at 3 months after discharge&#46; Three months after ICU stay patients were invited to attend the Follow-up Clinic for revaluation and PICS assessment&#46; In all moments patients were evaluated for both physical and non-physical PICS&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Physical components &#40;mobility impairment&#44; ICU-acquired weakness&#41; were clinically evaluated and the &#8220;Medical Research Council Scale for Muscle Strength&#8221; was used&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> A score &#8804;4 was considered for a decreased muscle strength and if present in at least two muscular groups was coded as ICU acquired weakness&#46; As for the psychological components &#40;anxiety&#44; depression&#44; post-traumatic stress disorder&#41;&#44; the questionnaires &#8220;Hospital Anxiety and Depression Scale&#8221; &#40;HADS&#41;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a> and &#8220;Post-Traumatic Stress Syndrome 14 Questions Inventory&#8221; &#40;PTSS-14&#41;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">12</span></a> were applied&#46; For Anxiety and Depression subscales&#44; a HADS &#62;10 was considered positive to the mood disorder and a HADS between 8 and 10 as being suggestive of the presence of the respective state &#40;the authors used the number ten as cut-off decision&#41;&#46; A PTSS &#8805;49 was considered positive to post-traumatic stress disorder risk&#46; Before 3 months&#8217; assessment&#44; questionnaires were sent by mail in advance&#46; In all moments patients received the questionnaires in advance and were able to answer then alone and quietly&#46; For the purpose of this study only data on PICS-P at 3 months after ICU discharge was analyzed&#44; independently how much time passed over the date of hospital discharge&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Caregivers assessment and caregiver&#39;s burden</span><p id="par0055" class="elsevierStylePara elsevierViewall">Caregiver was defined as the individual who provided the majority of support for the patient&#46; No cohabitation or legal relation with the patient was required&#46; Caregiver eligibility criteria included&#58; being a non-paid caregiver&#44; able to read and speak Portuguese and accept to participate in the study&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Caregivers were invited to the Patients&#8217; Follow-up Clinic to assess burden 3 months after the patient discharge and were evaluated in the same day as the patient&#46; Family burden was assessed using the &#8220;Zarit Burden Interview&#8221; which is a self-response questionnaire designed to expose the issues experienced by caregivers&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">13&#8211;16</span></a> Caregivers were asked to respond to a series of 22 questions about the impact of the patients&#8217; disabilities on their life&#46; For each item&#44; caregivers indicate how often they felt that specific burden &#40;never<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44; rarely<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44; sometimes<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#44; quite frequently<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#44; or nearly always<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41;&#46; Higher scores indicate greater caregiver distress&#46; As previously described by Zarit&#44; caregivers were classified as without overburden if the Zarit result was less than or equal to 21&#44; with low overburden if they reach a score between 22 and 40&#44; or with high overburden if they have a score of at least 41&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">17</span></a> The questionnaire was sent in advance by mail to all caregivers which allowed them to answered it quietly and lonely at home and then bring it to the Follow-up Clinic&#46; Caregiver&#39;s burden was assessed only at 3 months after patient&#39;s ICU discharge&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Ethical aspects</span><p id="par0065" class="elsevierStylePara elsevierViewall">It was a purely observational study without any implication in patients or caregivers&#8217; treatment&#46; All questionnaires&#44; both for patients and caregivers&#44; were preceded by an introduction where it was explained the purpose of the questionnaire and that it would be used in a scientific observational study&#46; Informed consent was waved&#46; Patients and caregivers voluntarily answered the questionnaires and confidentiality was maintained&#46; This study has been assessed and approved by the Institutional Ethics Committee&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Statistical analysis</span><p id="par0070" class="elsevierStylePara elsevierViewall">The relationship between caregiver&#39;s burden and the presence of different components of patient&#39;s PICS&#44; patient characteristics&#44; severity of illness and length of ICU stay were also analyzed&#46; Categorical variables were described through absolute &#40;<span class="elsevierStyleItalic">n</span>&#41; and relative &#40;&#37;&#41; frequencies&#44; and continuous variables were described as mean and standard deviation&#44; median&#44; percentiles&#44; and minimum and maximum when appropriate&#46; Hypotheses were tested regarding the distribution of continuous variables with non-normal distribution by using the non-parametric Mann&#8211;Whitney and Kruskal&#8211;Wallis tests&#44; depending on the nature of the hypothesis&#46; For categorical variables&#44; a Chi-square test or a Fisher&#39;s exact test was used&#44; as appropriate&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">All the reported <span class="elsevierStyleItalic">p</span>-values were two-sided&#44; and <span class="elsevierStyleItalic">p</span>-values of &#60;0&#46;05 were considered statistically significant&#46; All data were arranged&#44; processed and analyzed with SPSS&#174; v&#46;23&#46;0 &#40;Statistical Package for Social Sciences&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Patient&#39;s post-intensive care syndrome 3 months after ICU discharge</span><p id="par0080" class="elsevierStylePara elsevierViewall">During the study period 636 patients were admitted to ICU&#46; The most frequent admission motives were&#58; septic shock&#44; respiratory failure and post-major surgery&#46; The mortality rate was 19&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>120&#41;&#46; From surviving patients&#44; 161 were excluded from the study as they stayed less than 48<span class="elsevierStyleHsp" style=""></span>h at the ICU&#46; A total of 355 met the criteria to be followed by the Follow-up team and 245 were evaluated in the Follow-up Clinic 3 months after &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Fifty-seven patients died between ICU discharge and consultation and another 53 missed the clinic for different reasons&#46; Patient characteristics at 3 months Follow-up Clinic are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Three months after their ICU stay&#44; 106 patients &#40;43&#37;&#41; reported at least one component of PICS&#58; 20&#37; had depression&#44; 19&#37; anxiety&#44; 11&#37; post-traumatic stress disorder&#44; 11&#37; mobility impairment and 20&#37; ICU acquired weakness&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Caregivers&#8217; burden</span><p id="par0090" class="elsevierStylePara elsevierViewall">Over the study period&#44; 168 caregivers completed the survey&#44; with a response rate of 69&#37; as 77 patients failed to have their caregiver evaluated &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Exactly 50&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>84&#41; of the caregivers reported no overburden&#44; 34&#46;5&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>58&#41; experienced low overburden and 15&#46;5&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>26&#41; felt moderate to high overburden&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Impact of patient&#39;s PICS on caregiver&#39;s burden</span><p id="par0095" class="elsevierStylePara elsevierViewall">Impact of patient&#39;s PICS on caregiver&#39;s burden was finally analyzed on a sample of 168 patients and caregivers &#40;paired&#41;&#46; From this group&#44; two patients sent their answered questionnaires to the clinic but failed to be present there&#44; so they were not evaluated for physical limitations&#46; For that reason&#44; for comparison between caregivers and physical PICS only 166 pairs were considered&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Patient&#39;s anxiety and depression at 3 months &#40;median HADS of 12 for anxiety and Median HADS of 9 for depression&#41; has a statically significant association with higher degrees of caregiver&#39;s overburden &#40;Zarit &#8805; 41&#41;&#46; Physical components of patients&#8217; PICS at 3 months failed to show influence on caregivers&#8217; burden&#46; There were no differences in caregivers&#8217; burden regarding patients gender&#44; age&#44; SAPS II and ICU length of stay &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">The main finding of this study is that the presence of psychological components of Post Intensive Care Syndrome 3 months after ICU seems to influence negatively the overburden of caregivers&#46; On the other hand&#44; physical problems failed to show important impact in caregivers&#8217; overburden&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">As far as we know&#44; no study directly related the different components of PICS-P at 3 months with caregiver&#39;s burden at this same time&#46; We believe that our findings show an important relation between them that might help defining a strategy to identify and deal with caregivers at risk&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Several articles show that family members of critically ill patients are at risk for anxiety and depressive conditions&#44; and the combination of this is known as PICS-F&#44; though there is disagreement on what the term &#8220;caregiver burden&#8221; means&#46; A recent review from Van Beusekom et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">8</span></a> analyses the usual reported burden and the tools used to measure it&#46; It is discussed that caregivers have extensive burdens&#44; from changes in psychological status&#44; employment and lifestyle to decreased quality of life&#46; This review paper reported caregivers&#8217; burden prevalence between 16&#37; and 90&#37; during ICU or hospital stay&#44; between 12&#46;2&#37; and 26&#46;2&#37; at 3 months&#44; 4&#46;7&#37; and 36&#46;4&#37; at 6 months and between 22&#46;8&#37; and 44&#37; at 12 months after ICU discharge&#46; In our population&#44; the prevalence of patients&#8217; PICS is consistent with this and other studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Caring and dealing with an acutely ill loved one can be stressful and difficult to handle&#46; The psychological recovery of the family has tended to be forgotten and high rates of anxiety&#44; depression and Post-Traumatic Stress Disorder have been reported in caregivers&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">18</span></a> PICS-F and caregiver&#39;s burden should be assessed so caregivers can receive professional care if necessary&#46; It&#39;s not clear what is the best method for their assessment and several scales were used&#44; like Zarit Burden Interview&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">13</span></a> Hospital Anxiety and Depression Scale subscale<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a> or &#8220;Post-Traumatic Stress Syndrome 14 Questions Inventory &#40;PTSS-14&#41;&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">12</span></a> In this study&#44; Zarit Burden Interview was used because it&#39;s a simple self-answering questionnaire already translated&#44; used and validated in the Portuguese population&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">16</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Identifying predictors of adverse caregivers&#8217; outcome is fundamental for targeting intervention strategies&#46; Previous identified caregiver&#39;s risk factors for PICS-F are female gender&#44; younger relative&#44; being a spouse&#44; older patients age&#44; more chronic conditions&#44; lifestyle interference&#44; lower mastery and overload&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">6&#44;19</span></a> In our study patient gender&#44; age&#44; severity of illness and length of ICU stay also failed to show influence on caregiver&#39;s burden&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Few studies have evaluated patient specific predictors of caregivers&#8217; burden or PICS-F&#46; Some studies try to relate physical and functional PICS-P with caregiver burden with inconsistent results&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">13&#44;20&#8211;23</span></a> Swoboda et al&#46; found a relation between caregiver burden using a family impact survey and patient functional status using the Sickness Impact Profile&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">21</span></a> Choi et al&#46; finds a relation between caregiver burden using the Zarit interview and patient functional status using the Activities of Daily Living&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">20</span></a> All the studies show a small sample size in a single centre with important selection bias&#46; However other studies fail to find a significant relation between the family burden and the physical patient status<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">20&#44;22&#44;23</span></a> and are in accordance with our findings&#46; Notably Van Pelt et al&#46; finds a lack of relation between caregiver burden using the Centre for Epidemiologic Studies Depression and patient functional status using the Activities of Daily Living in their ICU cohort patients&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">22</span></a> Also in accordance with our study&#44; Choi et al&#46; show that remains high even caregiver distress if the patient regains pre-admission functional status&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">20</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Regarding studies that relate psychological PICS-P with caregiver burden&#58; we&#8217;ve only found one paper from Cameron et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">24</span></a> and this study is in line with ours&#46; They found that caregiver emotional distress was higher when the ARDS survivors reported more depressive symptoms&#46; The survivors&#8217; functional status&#44; expressed as the distance walked in 6<span class="elsevierStyleHsp" style=""></span>min&#44; was not associated with the informal caregiver emotional stress&#44; also in accordance with what we found&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Both previous studies and ours suggest that it is easier for relatives to accept and adapt to physical limitations than to deal with a psychologically wounded patient&#46; More studies are needed to understand caregiver role and burden in the care of ICU patients&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">This study has some limitations that have to be pointed out&#46; It is a single-centre study with a small sample that may be insufficient to extrapolate results onto the general population&#46; Furthermore&#44; the questionnaire was self-reported but not anonymous as mail was sent to the ICU patient&#44; so caregivers may have been afraid to be judged by their relatives or professionals for their answers&#46; More importantly we did not collect data on the caregiver characteristics that we could relate to its burden&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Additionally&#44; the responses of the 31&#37; of the caregivers who did not participate in the study could have a significant impact on the conclusions drawn&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In conclusion&#44; the caregiver&#39;s role is frequently under-looked by professionals&#44; but is nonetheless essential in the patient&#39;s recovery&#46; Our study shows that post ICU patient anxiety and depression play an important role in the burden of caregivers&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Identification of PICS-P is fundamental not only to define an early strategy for patients but also to prevent overburden and PICS-F in caregivers&#46; A structured multidisciplinary approach is crucial and should be designed to identify&#44; support and help caregivers at risk&#46; A more comprehensive study is required to better understand the connections between different components of PICS-P and PICS-F&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Funding</span><p id="par0165" class="elsevierStylePara elsevierViewall">None&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Contribution of the authors</span><p id="par0170" class="elsevierStylePara elsevierViewall">JT&#44; DC&#44; EM&#44; CV&#44; AF&#44; RA and EG designed the study and managed data collection&#46; Analysis and interpretation of data was undertaken by CCD&#46; JT and EG wrote the first manuscript draft and were responsible for subsequent collation of inputs and redrafting&#46; DC&#44; EM and RA helped to revise the manuscript&#46; All authors read and approved the final manuscript&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Conflict of interests</span><p id="par0175" class="elsevierStylePara elsevierViewall">None&#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 evaluate patient post-intensive care syndrome &#40;PICS-P&#41; and caregiver burden 3 months after discharge from the Intensive Care Unit &#40;ICU&#41; and determine the impact of different components of PICS-P upon caregiver burden&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A prospective observational study was conducted over 26 months &#40;January 2013&#8211;February 2015&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Setting</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Medical-surgical ICU and follow-up consultation in Portugal&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Patients or participants</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Patients discharged after a minimum of 2 days in the ICU&#46; Caregiver inclusion criteria&#58; not paid&#44; written and spoken Portuguese&#44; and agreement to participate in the study&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Main variables of interest</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">In ICU&#58; Patient gender&#44; age&#44; severity of illness &#40;SAPS II&#41; and length of ICU stay&#46; At 3 months caregiver burden&#44; physical &#40;reduced mobility&#44; weakness acquired in the ICU&#41; and psychological components of PICS &#40;anxiety&#44; depression&#44; post-traumatic stress disorder&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A total of 168 caregivers completed the survey &#40;response rate of 69&#37;&#41;&#46; A low degree of overburden was reported by 34&#46;5&#37; of caregivers&#44; while 15&#46;5&#37; showed moderate to high levels of overburden&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Patient anxiety and depression 3 months after ICU discharge significantly influenced the presence of caregiver burden &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;030 vs <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;008&#41;&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">When physical components of PICS-P were evaluated&#44; no influence on caregiver burden was observed&#46; Patient demographics&#44; severity of illness and length of stay also failed to influence caregiver burden&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The presence of psychological components of PICS-P 3 months after ICU seems to have a negative impact upon caregiver burden&#46; On the other hand&#44; physical problems showed no important impact upon caregiver overburden&#46;</p></span>"
        "secciones" => array:7 [
          0 => array:2 [
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          1 => array:2 [
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            "titulo" => "Design"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Objetivo</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Caracterizar el s&#237;ndrome poscuidados intensivos de los pacientes &#40;PICS-P&#41; y la sobrecarga de los cuidadores a los 3 meses del alta de la Unidad de Cuidados Intensivos &#40;UCI&#41;&#46; Averiguar c&#243;mo la sobrecarga es influida por los diferentes componentes del PICS-P&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Dise&#241;o</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo observacional de 26 meses &#40;enero de 2013-febrero de 2015&#41;&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">&#193;mbito</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">UCI m&#233;dico-quir&#250;rgica y consulta de seguimiento en Portugal&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Pacientes o participantes</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Pacientes dados de alta despu&#233;s de 2 o m&#225;s d&#237;as en la UCI&#46; Criterios de inclusi&#243;n de los cuidadores&#58; no cobrar&#44; leer y hablar portugu&#233;s y aceptar participar en el estudio&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Principales variables de inter&#233;s</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">En la UCI&#58; g&#233;nero&#44; edad&#44; gravedad de la enfermedad &#40;SAPS II&#41; y estancia en la UCI&#46; A los 3 meses&#58; sobrecarga del cuidador&#59; componentes f&#237;sicos &#40;reducci&#243;n de la movilidad&#44; debilidad adquirida en la UCI&#41; y ps&#237;quicos &#40;ansiedad&#44; depresi&#243;n&#44; s&#237;ndrome de estr&#233;s postraum&#225;tico&#41; del PICS-P&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Un total de 168 cuidadores respondieron al cuestionario de sobrecarga &#40;tasa de respuesta del 69&#37;&#41;&#46; El nivel de sobrecarga era bajo en el 34&#44;5&#37; de los casos y moderado a alto en el 15&#44;5&#37;&#46; A los 3 meses&#44; la presencia de ansiedad y depresi&#243;n en los pacientes influy&#243; de forma significativa en la sobrecarga de los cuidadores &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;030 y p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;008&#44; respectivamente&#41;&#46; No se encontr&#243; ninguna influencia de los componentes f&#237;sicos del PICS-P&#44; la edad&#44; el g&#233;nero&#44; el SAPS II o la estancia en UCI sobre la sobrecarga&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">La presencia de componentes psicol&#243;gicos de PICS-P a los tres meses parece influir de forma negativa en el nivel de sobrecarga de los cuidadores&#46; Los problemas f&#237;sicos parecen no tener impacto sobre dicha sobrecarga&#46;</p></span>"
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            "titulo" => "Dise&#241;o"
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            "identificador" => "abst0050"
            "titulo" => "&#193;mbito"
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          3 => array:2 [
            "identificador" => "abst0055"
            "titulo" => "Pacientes o participantes"
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            "identificador" => "abst0060"
            "titulo" => "Principales variables de inter&#233;s"
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            "identificador" => "abst0065"
            "titulo" => "Resultados"
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            "identificador" => "abst0070"
            "titulo" => "Conclusiones"
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          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Flow chart of patient and caregiver enrolment &#40;in attachment&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; <span class="elsevierStyleItalic">n</span>&#44; number&#59; Min&#44; Minimum&#59; Max&#44; Maximum&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Patient Age&#44; median &#40;min-max&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">61 years &#40;15&#8211;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Patient sex&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">162 &#40;66&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">83 &#40;34&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">SAPS II&#44; median &#40;min-max&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45 &#40;15&#8211;72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">ICU stay&#44; median &#40;min-max&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 days &#40;2&#8211;110&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Days of sedation&#44; median &#40;min-max&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 day &#40;0&#8211;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Days of mechanical ventilation&#44; median &#40;min-max&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 days &#40;0&#8211;58&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Patient characteristics at follow-up consultation 3 months after ICU&#46;</p>"
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; <span class="elsevierStyleItalic">n</span>&#44; number&#59; Min&#44; minimum&#59; Max&#44; Maximum&#59; HADS&#44; Hospital Anxiety and Depression Scale&#59; PTSS 14&#44; Post-Traumatic Stress Syndrome 14 Questions Inventory&#46;</p>"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" 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">No overburden<br>&#40;Zarit &#8804; 21&#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">Low overburden &#40;Zarit 22&#8211;40&#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">Moderate to High overburden &#40;Zarit &#8805; 41&#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<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Patient gender&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26 &#40;31&#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">20 &#40;34&#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;35&#37;&#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;885&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58 &#40;69&#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">38 &#40;66&#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">17 &#40;65&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Patient Age&#44; median &#40;min-max&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60 &#40;16&#8211;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67 &#40;20&#8211;82&#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 &#40;26&#8211;83&#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;108&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">SAPS II&#44; median &#40;min-max&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37 &#40;11&#8211;72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41 &#40;2&#8211;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33 &#40;5&#8211;72&#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;169&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Days in ICU stay median &#40;min-max&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;2&#8211;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;2&#8211;110&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;5&#8211;26&#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;530&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Mobility impairment&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">76 &#40;91&#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">43 &#40;77&#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">20 &#40;77&#37;&#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;059&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;9&#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">13 &#40;23&#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">6 &#40;23&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">ICU acquired weakness&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61 &#40;73&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Depression &#40;HADS&#41;&#44; median &#40;min-max&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;0&#8211;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;0&#8211;16&#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;1&#8211;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">0&#46;008</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">PTSS 14&#44; median &#40;min-max&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27 &#40;14&#8211;83&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32 &#40;14&#8211;65&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;178<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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