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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110"><span class="elsevierStyleBold">Introducci&#243;n</span></span><p id="par0250" class="elsevierStylePara elsevierViewall">La enfermedad por coronavirus 2019 &#40;COVID-19&#41; se trata de una enfermedad relativamente nueva en nuestro medio&#44; habiendo sido notificada por primera vez en Wuhan &#40;China&#41;&#44; en diciembre de 2019&#44; declar&#225;ndose el 11 de marzo de 2020 como pandemia por parte de la Organizaci&#243;n Mundial de la Salud &#40;OMS&#41; por los alarmantes niveles de propagaci&#243;n y gravedad&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">La aparici&#243;n de esta nueva enfermedad y el aumento exponencial de pacientes que precisaron ingreso en la Unidad de Cuidados Intensivos &#40;UCI&#41; por hipoxemia grave secundaria a neumon&#237;a bilateral&#44; no s&#243;lo colapsaron las UCI<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">1</span></a> sino que multiplicaron los pacientes con secuelas m&#225;s o menos invalidantes provocadas por la estancia prolongada en la UCI&#44; el distr&#233;s respiratorio&#44; la terapia agresiva &#40;incluyendo maniobras de prono&#41;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> y las derivadas del virus&#46; Hasta el momento&#44; se han realizado una docena de estudios que eval&#250;an aspectos como el deterioro cognitivo<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a>&#44; secuelas motoras con impacto en la calidad de vida diaria<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a> &#40;dolor o malestar&#44; ansiedad o depresi&#243;n&#44; cuidado personal y actividad habitual&#41;&#44; nivel de fatiga percibido<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">5</span></a>&#44; intolerancia al ejercicio&#44; disnea de moderados esfuerzos&#44; astenia&#44; as&#237; como limitaciones en la capacidad f&#237;sica y su influencia sobre la salud psicol&#243;gica<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6&#44;7</span></a>&#44; haciendo necesario el abordaje multidisciplinar de estos pacientes por la complejidad de los mismos&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Esta nueva realidad ha motivado que en algunos hospitales se hayan creado distintas herramientas para el seguimiento de estos pacientes tan complejos&#44; habi&#233;ndose creado para ello circuitos espec&#237;ficos en distintos hospitales&#44; as&#237; como la especial implicaci&#243;n desde el Grupo &#205;taca &#40;grupo de colaboraci&#243;n y trabajo para la prevenci&#243;n&#44; diagn&#243;stico&#44; seguimiento y tratamiento de pacientes con s&#237;ndrome pos Cuidados Intensivos &#91;SPCI&#93;&#41; lanzando el estudio CORONAPICS a nivel nacional para describir las caracter&#237;sticas del SPCI en supervivientes de la pandemia COVID-19&#44; entre otros objetivos&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Nuestro estudio pretende abordar las secuelas al mes del alta hospitalaria de los pacientes con neumon&#237;a bilateral grave por COVID-19&#44; desde un punto multidisciplinar&#44; por parte de Medicina Intensiva&#44; Medicina F&#237;sica y Rehabilitaci&#243;n&#44; Endocrinolog&#237;a y Nutrici&#243;n&#44; Salud Mental y Neumolog&#237;a&#46; Los estudios existentes hasta el momento<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a> incluyen a los supervivientes por COVID-19 tras ingreso en Cuidados Intensivos sin hacer distinci&#243;n en cuanto a la terapia respiratoria empleada durante su ingreso&#44; por lo que se pretende analizar si existen diferencias entre los pacientes que recibieron oxigenoterapia con alto flujo exclusivamente&#44; o aquellos que precisaron escalar a VMI&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Pacientes y m&#233;todos</span><p id="par0025" class="elsevierStylePara elsevierViewall">Estudio prospectivo observacional de los pacientes que precisaron ingreso en la UCI del Hospital Virgen de la Victoria de M&#225;laga desde abril del a&#241;o 2020 hasta octubre de 2021 por neumon&#237;a grave por COVID-19&#46; Los pacientes ingresados en UCI fueron todos aquellos pacientes susceptibles de medidas agresivas&#44; con necesidad de ox&#237;geno mayor a 15 lpm y PaO2&#47;FiO2 &#60; 200&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Se incluyeron en el estudio los pacientes supervivientes&#44; siendo citados en el circuito de Atenci&#243;n Multidisciplinar Pos COVID&#44; donde fueron valorados en &#171;consulta de acto &#250;nico&#187; por Medicina F&#237;sica y Rehabilitaci&#243;n&#44; Endocrinolog&#237;a&#44; Neumolog&#237;a&#44; Salud Mental y Medicina Intensiva&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Se excluyeron los pacientes que fueron remitidos desde otros hospitales&#44; al tratarse nuestro centro del Hospital de referencia del &#225;rea Costa del Sol y de la Serran&#237;a de Ronda&#44; as&#237; como los pacientes extranjeros por la dificultad para la realizaci&#243;n del seguimiento de los mismos&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">En la primera visita&#44; correspondiente al mes del alta hospitalaria&#44; se incluyeron los siguientes registros&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Historia cl&#237;nica detallando calidad de vida previa&#44; independencia para las actividades b&#225;sicas de la vida diaria&#44; necesidad de ayuda para la marcha&#44; cansancio&#44; h&#225;bito de ejercicio f&#237;sico&#44; dolor y debilidad&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Recogida de informaci&#243;n acerca del ingreso&#58; d&#237;as de ingreso en UCI y hospitalario&#44; terapia respiratoria empleada&#44; d&#237;as de VMI&#44; tratamiento administrado&#44; d&#237;as de relajante muscular y ciclos de prono&#46;</p></li></ul></p><p id="par0055" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8728;</span><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Secuelas&#58;</span> otorrinolaringol&#243;gicas &#40;ORL&#41;&#44; psicol&#243;gicas&#47;psiqui&#225;tricas&#44; consumo de benzodiacepinas y antidepresivos&#44; oxigenoterapia al alta&#44; disnea &#40;escala de MRCm&#41;&#44; espirometr&#237;a&#44; kilos de peso perdidos tras el ingreso hospitalario&#44; masa celular corporal &#40;BCM&#41; y masa celular corporal indexada &#40;BCMI&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8728;</span><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Exploraci&#243;n&#58;</span> Balance articular global y balance muscular global &#40;MRC modificada&#41;&#46; Fuerza de agarre con dinam&#243;metro de mano&#46; Presiones musculares respiratorias&#58; presi&#243;n inspiratoria m&#225;xima &#40;Pimax&#41; y presi&#243;n espiratoria m&#225;xima &#40;Pemax&#41;&#46; Test de marcha seis minutos</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8728;</span><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Escalas&#47;cuestionarios de calidad de vida&#58;</span> escala FACIT-F&#44; escala EuroQol-5D&#44; escala Barthel&#46; Test de evaluaci&#243;n cognitiva de Montreal &#40;MoCA&#41;</p></li></ul></p><p id="par0075" class="elsevierStylePara elsevierViewall">Una vez valorados los pacientes y si presentaban alg&#250;n tipo de d&#233;ficit&#44; se les indicaba la posibilidad de realizar un programa de rehabilitaci&#243;n integral&#44; presencial o domiciliario &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41; en funci&#243;n de las siguientes caracter&#237;sticas&#58;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Las indicaciones para realizar un programa de rehabilitaci&#243;n presencial fueron&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Pacientes COVID-19 con PCR negativa&#44; con capacidad de deambulaci&#243;n independiente&#44; estables&#44; que presentan disnea de moderados &#8211; grandes esfuerzos y&#47;o cansancio con esfuerzos moderados&#44; fr&#225;giles con SPPB&#60;10 y&#47;o necesidad de O<span class="elsevierStyleInf">2</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Buen nivel cognitivo y capacidad de colaboraci&#243;n&#46;</p></li></ul></p><p id="par0095" class="elsevierStylePara elsevierViewall">Las indicaciones para realizar un programa de rehabilitaci&#243;n domiciliario fueron&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Pacientes fr&#225;giles sin necesidad de O<span class="elsevierStyleInf">2</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Pacientes que no pod&#237;an acudir a un programa de rehabilitaci&#243;n presencial&#46;</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120"><span class="elsevierStyleBold">Consideraciones &#233;ticas</span></span><p id="par0110" class="elsevierStylePara elsevierViewall">El estudio se realiz&#243; de acuerdo con la Declaraci&#243;n de Helsinki y los principios de Buena Pr&#225;ctica Cl&#237;nica y fue aprobado por el Comit&#233; de &#201;tica Institucional del HVV &#40;proyecto POSTUCI21 - 1654-N-21&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">La identidad de los sujetos es confidencial&#44; identificando cada sujeto mediante n&#250;meros que permitieron realizar el emparejamiento de los datos entre las distintas consultas&#44; llev&#225;ndose a cabo la realizaci&#243;n de una base de datos desde donde poder extrapolar los datos y obtener las conclusiones del presente estudio&#46; Los pacientes incluidos en el estudio proporcionaron su consentimiento informado para la utilizaci&#243;n de sus datos con car&#225;cter an&#243;nimo&#44; sabiendo que se trata de un estudio descriptivo en cuanto a sus caracter&#237;sticas basales&#44; autorizando a su seguimiento a largo plazo&#46; Los pacientes podr&#225;n revocar el consentimiento informado para la participaci&#243;n en este estudio en el momento en el que as&#237; lo estimen oportuno&#46; &#218;nicamente un paciente que no quiso participar en el estudio no deseando firmar el consentimiento informado para el an&#225;lisis de los resultados obtenidos en consulta&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">An&#225;lisis estad&#237;stico</span><p id="par0120" class="elsevierStylePara elsevierViewall">Las caracter&#237;sticas demogr&#225;ficas de los pacientes se expresaron como media y desviaci&#243;n est&#225;ndar para las variables continuas y valores absolutos junto con porcentajes para las variables categ&#243;ricas&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Los participantes se clasificaron en dos grupos de acuerdo con la terapia respiratoria empleada durante su ingreso en la UCI&#58; ONAF o VMI&#46; El an&#225;lisis descriptivo de las caracter&#237;sticas sociodemogr&#225;ficas y cl&#237;nicas de los pacientes&#44; se realiz&#243; el test de <span class="elsevierStyleItalic">X</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span> para la igualdad de medias y la prueba de Levene de calidad de varianzas en las variables cuantitativas y la prueba de <span class="elsevierStyleItalic">X</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span> en las variables cualitativas&#44; aplicando la prueba exacta de Fisher cuando se requiri&#243;&#44; para valorar si exist&#237;a alguna diferencia estad&#237;sticamente significativa entre las variables estudiadas y el tipo de terapia respiratoria empleada&#44; con un nivel de confianza de 95&#37;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Mediante un modelo de regresi&#243;n log&#237;stica binomial&#44; se ha realizado el an&#225;lisis multivariable para evaluar los predictores de plexopat&#237;a braquial&#44; balance muscular limitado en miembros inferiores y neuropat&#237;a distal&#46; Se introdujeron en el an&#225;lisis multivariable las variables en las que se observ&#243; asociaci&#243;n estad&#237;stica en el univariante&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Todos los an&#225;lisis estad&#237;sticos de la base de datos se han realizado con el programa estad&#237;stico IBM SPSS Statistics V&#46;24 &#40;IBM&#41;&#46; Se ha considerado estad&#237;sticamente significativo p &#60; 0&#44;05&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Resultados</span><p id="par0140" class="elsevierStylePara elsevierViewall">Un total de 360 pacientes fueron ingresados en la UCI del Hospital Virgen de las Victoria desde abril del a&#241;o 2020 hasta octubre de 2021&#46; Se incluyeron en la consulta multidisciplinar pos COVID 104 pacientes&#46; Respecto a los 256 pacientes restantes&#44; 127 pacientes fallecieron durante su ingreso hospitalario&#44; 74 pacientes no cumplieron los criterios de inclusi&#243;n&#58; 28 fueron trasladados desde otros hospitales&#44; 45 pacientes se trataban de pacientes extranjeros y &#250;nicamente un paciente no dese&#243; participar en el seguimiento y 55 pacientes perdieron el seguimiento tras el alta hospitalaria&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Las caracter&#237;sticas sociodemogr&#225;ficas y cl&#237;nicas de los pacientes en funci&#243;n de la terapia respiratoria empleada&#58; ONAF o VMI se muestra en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46; De los 56 pacientes que recibieron VMI&#44; 29 pacientes fueron intubados directamente al ingreso&#44; 14 en las primeras 24 horas de ingreso&#44; siete a las 48 horas de ingreso y seis pasado ese tiempo&#46; La terapia respiratoria empleada previamente a la intubaci&#243;n orotraqueal fue en todos los casos ONAF&#46; Hubo diferencia estad&#237;sticamente significativa &#40;p &#60; 0&#44;001&#41; en el n&#250;mero de d&#237;as de ingreso en UCI&#44; con una media de 8&#44;97 &#40;DE 3&#44;86&#41; en pacientes con ONAF vs&#46; 32&#44;82 &#40;DE 21&#44;03&#41; en pacientes con VMI y en el n&#250;mero de d&#237;as de ingreso hospitalario&#44; con una media de 24&#44;12 &#40;DE 16&#44;72&#41; ONAF vs&#46; 67&#44;23 &#40;DE 59&#44;06&#41; VMI&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">La escala APACHE II obtuvo resultados similares en ambos grupos de estudio&#44; con una media de 8&#44;18 &#40;DE 3&#44;17&#41; en ONAF vs&#46; 9&#44;07 &#40;DE 4&#44;41&#41; en VMI&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Los s&#237;ntomas presentes al mes del alta hospitalaria se describen en la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#44; encontrando diferencias entre ambas terapias de soporte respiratorio en cuanto a las secuelas ORL encontrando casos de afon&#237;a&#44; granuloma gl&#243;tico&#44; estenosis traqueal&#44; hipoacusia y f&#237;stula traqueostoma en el grupo de VMI&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">Las secuelas f&#237;sicas presentes en la consulta de Rehabilitaci&#243;n con diferencias significativas fueron la neuropat&#237;a distal &#40;p &#61; 0&#44;005&#41; y la limitaci&#243;n del balance muscular en miembros inferiores &#40;p &#61; 0&#44;024&#41;&#46; La plexopat&#237;a braquial se describi&#243; &#250;nicamente en los pacientes que precisaron VMI &#40;p &#61; 0&#44;024&#41;&#46; No se encontraron diferencias en los procesos dolorosos estudiados &#40;cervicobraquialgia&#44; neurop&#225;tico&#44; lumboci&#225;tica&#44; s&#237;ndrome facetario&#44; entesopat&#237;a m&#250;ltiple y meralgia parest&#233;sica&#41;&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">En la primera consulta realizada por parte de Rehabilitaci&#243;n &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#44; se realiz&#243; el test de la marcha&#44; la medici&#243;n de la Pimax y Pemax y la dinamometr&#237;a de mano&#46; Los hombres obtuvieron mejores resultados &#40;p &#61; 0&#44;010&#41; en la Pimax en el grupo de ONAF con una media de 112&#44;10 cm H2O &#40;DE 33&#44;04 cmH<span class="elsevierStyleInf">2</span>O&#41;&#44; en comparaci&#243;n con con 89&#44;81 cmH<span class="elsevierStyleInf">2</span>O &#40;DE 34&#44;71 cmH<span class="elsevierStyleInf">2</span>O&#41; en el subgrupo de VMI&#46; El test de prensi&#243;n isom&#233;trica mediante el dinam&#243;metro de mano mostr&#243; disminuci&#243;n de fuerza de agarre con una media en mano derecha de 20&#44;67 kg &#40;&#177; 8&#44;27&#41; en VMI vs&#46; 31&#44;8 kg &#40;&#177; 11&#44;59&#41; en ONAF&#44; y una media en mano izquierda de 19&#44;39 kg &#40;&#177; 8&#44;45&#41; en VMI vs&#46; 30&#44;26 kg &#40;&#177; 12&#44;74&#41; en ONAF&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">De los 104 pacientes a los que se realiz&#243; el seguimiento en la consulta multidisciplinar pos UCI&#44; no precisaron rehabilitaci&#243;n un total de 23 pacientes&#46; Respecto a los 81 pacientes restantes&#44; 36&#44;54&#37; precisaron rehabilitaci&#243;n grupal y 41&#44;35&#37; domiciliaria &#40;p &#61; 0&#44;056&#41;&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Otras escalas realizadas fueron&#58; el &#237;ndice de Barthel con 95&#44;28 puntos &#40;DE 14&#44;44 puntos&#41; en ONAF y 89&#44;12 &#40;DE 20&#44;70 puntos&#41; en VMI&#59; la escala EQ-5D con diferencia estad&#237;sticamente significativa en cuanto a la calidad de vida percibida a los seis meses entre los subgrupos estudiados &#40;p &#61; 0&#44;004&#41;&#44; sin existir diferencia en la primera revisi&#243;n &#40;p &#61; 0&#44;301&#41; ni en el resto de los aspectos valorados en la escala&#59; y la escala FACIT a los seis meses &#40;p &#61; 0&#44;099&#41;&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Tras el an&#225;lisis multivariable &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41; para evaluar los factores de riesgo asociados con la plexopat&#237;a braquial&#44; balance muscular limitado en miembros inferiores y neuropat&#237;a distal&#44; no se encontr&#243; asociaci&#243;n estad&#237;sticamente significativa&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Discusi&#243;n</span><p id="par0185" class="elsevierStylePara elsevierViewall">En nuestro estudio no se aprecian diferencias estad&#237;sticamente significativas en cuanto a las secuelas f&#237;sicas percibidas tras el alta hospitalaria en funci&#243;n de la terapia respiratoria empleada&#44; ya fuera ONAF o VMI prolongada&#44; sin encontrar diferencias tampoco entre los pacientes que precisaron rehabilitaci&#243;n&#46; Aun sin existir diferencias significativas&#44; m&#225;s del doble de pacientes del grupo de VMI precisaron rehabilitaci&#243;n grupal con respecto a los pacientes que requirieron ONAF&#44; pudiendo generar incertidumbre acerca de los resultados&#46; El protocolo de rehabilitaci&#243;n domiciliaria fue igual al presencial salvo por la supervisi&#243;n por parte de un fisioterapeuta&#44; aspecto que hizo m&#225;s individualizado el tratamiento&#44; al mismo tiempo que el paciente se compromet&#237;a a acudir al mismo&#44; teniendo una actitud positiva hacia el programa con una buena adherencia&#46; En el programa domiciliario&#44; no hubo supervisi&#243;n y ha dependido fundamentalmente de la concienciaci&#243;n que tuviera el paciente para asumir esta terapia&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Desde el punto de vista respiratorio&#44; pr&#225;cticamente el doble de pacientes dentro del grupo de VMI describi&#243; disnea grado 2-3 mMRC&#46; Llama la atenci&#243;n la ausencia de significaci&#243;n en cuanto a la necesidad de oxigenoterapia al alta&#44; sin observar un menor porcentaje dentro del grupo de ONAF con respecto a VMI&#46; Estos datos resultan interesantes e invitan a la formulaci&#243;n de hip&#243;tesis al respecto&#44; en cuanto a la duraci&#243;n del distr&#233;s y el tiempo de reparaci&#243;n pulmonar&#46; El hecho de que pacientes que fueron tratados con alto flujo<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a> no presenten diferencias significativas con respecto a la VMI plantea dos hip&#243;tesis fundamentalmente&#58; menor tiempo de ingreso en Cuidados Intensivos y menor tiempo de ingreso hospitalario total&#44; pasando los &#250;ltimos d&#237;as del distr&#233;s en domicilio&#59; y una segunda hip&#243;tesis que defiende que el apoyo no invasivo conlleva riesgo de lesi&#243;n pulmonar autoinfligida por el paciente afectando negativamente a los s&#237;ntomas percibidos<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">10&#44;11</span></a>&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Se ha realizado este estudio con el inter&#233;s de estudiar las posibles diferencias en cuanto a las secuelas de los pacientes en funci&#243;n de la terapia respiratoria empleada durante su ingreso en Cuidados Intensivos&#44; al existir escaso n&#250;mero de estudios que hayan realizado una comparaci&#243;n directa entre ambos grupos y no existir hasta la fecha recomendaciones respecto al momento &#243;ptimo de inicio de la oxigenoterapia nasal de alto flujo &#40;ONAF&#41; y sus posibles efectos<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">12&#44;13</span></a>&#46; En los estudios encontrados&#44; los supervivientes de UCI ten&#237;an puntuaciones de disnea y funci&#243;n pulmonar similares a los pacientes que no precisaron ingreso en UCI&#44; pese a presentar peores resultados en la tomograf&#237;a computarizada &#40;TC&#41; y rendimiento menor en las actividades habituales<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">14</span></a>&#46; En cuanto a las pruebas respiratorias funcionales mediante la Pimax y Pemax&#44; as&#237; como el volumen ventilatorio m&#225;ximo han sido estudiados en distintos perfiles de pacientes&#44; existiendo correlaci&#243;n entre la fuerza de prensi&#243;n manual como determinante de la fuerza de los m&#250;sculos perif&#233;ricos y la fuerza de los m&#250;sculos pulmonares en comparaci&#243;n con pacientes sanos<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a>&#46; Nuestro estudio ha encontrado<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a> diferencias significativas en el n&#250;mero de d&#237;as de ingreso en Cuidados Intensivos y hospitalario en funci&#243;n de la terapia respiratoria que precisaron durante su ingreso &#40;p &#60; 0&#44;001&#41;&#44; sin encontrar diferencia a nivel de las pruebas respiratorias realizadas&#44; como la espirometr&#237;a &#40;FVC&#44; FEV1 y FEV1&#47;FVC&#41;&#46; &#218;nicamente se encontraron diferencias significativas en la Pimax en los varones estudiados&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">El SPCI<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">17&#8211;19</span></a> presenta niveles cl&#237;nicamente significativos de s&#237;ntomas depresivos&#44; ansiedad y s&#237;ntomas de estr&#233;s postraum&#225;tico<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a>&#44; habiendo sido acu&#241;ado el t&#233;rmino s&#237;ndrome pos COVID-19&#44; s&#237;ndrome pos COVID-19 persistente &#40;PPCS&#41; o COVID prolongado<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">21</span></a>&#46; Existen estudios acerca de la calidad de vida o secuelas tras el alta hospitalaria&#44; en neumon&#237;a por COVID-19 no cr&#237;tico<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">22</span></a> examinando el impacto de la misma en la funci&#243;n pulmonar&#44; calidad de vida relacionada con la salud y disnea percibida&#46; La aparici&#243;n de deterioro cognitivo en infecci&#243;n leve sintom&#225;tica por COVID-19&#44; evaluado mediante el test de MOCA&#44; est&#225; descrita&#44; si bien se desconoce la patogenia de esta complicaci&#243;n<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a>&#46; En cuanto al impacto en la calidad de vida diaria&#44; evaluada mediante la escala EQ-5D-5L&#44; se han encontrado diferencias<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a> en pacientes supervivientes de UCI con respecto a casos leves o moderados&#46; Otros estudios<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a> muestran alteraci&#243;n en movilidad&#44; autocuidado&#44; dolor&#44; ansiedad o depresi&#243;n&#44; actividad habitual en ambos grupos&#44; con una ligera diferencia en el dolor en el grupo de la UCI&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">La rehabilitaci&#243;n es fundamental en el seguimiento multidisciplinar de los pacientes tras el alta hospitalaria<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a> para la recuperaci&#243;n de enfermedades graves asociadas con el COVID-19&#44; optimizar su independencia y facilitar la reintegraci&#243;n en la comunidad&#44; por lo que debe promoverse una rehabilitaci&#243;n temprana<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">25&#8211;27</span></a>&#46; Nuestro estudio muestra asociaci&#243;n entre VMI y plexopat&#237;a braquial&#44; neuropat&#237;a distal y balance muscular limitado en miembros inferiores&#46; No obstante&#44; tras el an&#225;lisis multivariable no se observaron diferencias estad&#237;sticamente significativas&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Desde el punto de vista nutricional&#44; encontramos diferencias significativas en BCM y BCMI<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">28</span></a> en pacientes que precisaron VMI&#44; si bien los resultados parecen guardar relaci&#243;n con un mayor n&#250;mero de d&#237;as de ingreso en UCI e ingreso hospitalario&#44; habiendo contribuido con peores resultados nutricionales en estos pacientes&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Las principales limitaciones de este estudio han sido el peque&#241;o tama&#241;o muestral adem&#225;s del hecho de que no todos los pacientes fueron valorados por todos los especialistas incluidos en el programa multidisciplinar&#44; habiendo realizado determinadas pruebas&#44; como la espirometr&#237;a&#44; en los pacientes con peor evoluci&#243;n desde el punto de vista respiratorio al alta hospitalaria&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Se excluyeron del estudio&#44; lamentablemente&#44; un alto n&#250;mero de pacientes dado que nuestro hospital es referente de otras &#225;reas sanitarias&#44; por lo que del total de pacientes que sobrevivieron&#44; se excluyeron 74 pacientes al pertenecer a otros hospitales o tratarse de pacientes extranjeros que volvieron a sus pa&#237;ses de origen&#46; Adem&#225;s se perdieron 55 pacientes que no fueron incluidos en el estudio al no disponer de datos acerca de sus secuelas al mes del alta hospitalaria&#44; probablemente producto del cierre de agendas de la consulta pos COVID en la tercera ola&#44; en enero 2021&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Otro factor a tener en cuenta en el estudio es la medicaci&#243;n administrada durante su ingreso&#44; sin existir diferencia en cuanto a dexametasona y tocilizumab&#44; si la observamos con lopinavir&#47;ritonavir e hidrocloroquina&#44; administrados fundamentalmente en los pacientes con VMI&#46; Este hecho podr&#237;a generar sesgos&#44; si bien estos f&#225;rmacos a fecha de 4 de julio de 2020 fueron desaconsejados en su uso por la OMS aceptando la recomendaci&#243;n del Grupo directivo internacional del ensayo Solidarity&#44; por la que la reducci&#243;n de la mortalidad en enfermos COVID-19 no justificaba su uso&#46; Esto mismo ocurri&#243; con el interfer&#243;n beta-1A&#44; existiendo evidencia y datos que demostraron la no disminuci&#243;n de mortalidad y&#47;o de necesidad de VM<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a>&#46; Por tanto&#44; no consideramos que su utilizaci&#243;n en los pacientes seleccionados de la primera ola haya podido generar sesgos entre ambos grupos&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Es preciso el seguimiento a largo plazo y aumentar el tama&#241;o muestral para caracterizar mejor las consecuencias de la COVID-19&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conclusiones</span><p id="par0235" class="elsevierStylePara elsevierViewall">Los resultados obtenidos tras el estudio multivariable sugieren no existir diferencias estad&#237;sticamente significativas en cuanto a las secuelas f&#237;sicas percibidas tras el alta hospitalaria en funci&#243;n de la terapia respiratoria empleada&#44; ya fuera ONAF o ventilaci&#243;n mec&#225;nica prolongada&#44; si bien son precisos m&#225;s estudios para poder obtener conclusiones al respecto&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145"><span class="elsevierStyleBold">Contribuci&#243;n de los autores</span></span><p id="par0240" class="elsevierStylePara elsevierViewall">La consulta multidisciplinar ha estado constituida por los servicios de Medicina Intensiva&#44; Medicina F&#239;sica y Rehabilitaci&#243;n&#44; Endocrinolog&#237;a y Nutrici&#243;n&#44; Salud Mental y Neumolog&#237;a&#46; La contribuci&#243;n por parte de los distintos servicios citados ha estado representada por el Dr&#46; Jos&#233; M&#46; Garc&#237;a Almeida como m&#233;dico especialista en Endocrinolog&#237;a y Nutrici&#243;n&#59; la Dra&#46; Elma Avanesi-Molina como m&#233;dico especialista en Salud Mental&#59; la Dra&#46; Eva Cabrera-C&#233;sar como m&#233;dico especialista en Neumolog&#237;a&#44; la Dra&#46; Pilar Mart&#237;nez-L&#243;pez como m&#233;dico especialista en Medicina Intensiva y Adela M&#46; G&#243;mez-Gonz&#225;lez como especialista en Medicina F&#237;sica y Rehabilitaci&#243;n&#46; El art&#237;culo ha sido dirigido por las Dras&#46; Pilar Mart&#237;nez-L&#243;pez y Adela M&#46; G&#243;mez-Gonz&#225;lez&#44; como principales creadoras de la consulta pos COVID-19&#44; con la colaboraci&#243;n de la directora m&#233;dica hospitalaria&#44; la Dras&#46; Maria A&#46; Estecha-Foncea&#46; La elaboraci&#243;n del proyecto&#44; b&#250;squeda bibliogr&#225;fica&#44; discusi&#243;n y conclusiones ha sido realizada por la Dra&#46; Ana M&#46; S&#225;nchez-Garc&#237;a&#44; con la revisi&#243;n externa por parte del Dr&#46; Pedro L&#46; S&#225;nchez-Fern&#225;ndez&#44; Manuel F&#46; Jim&#233;nez-Navarro y la Dra&#46; Mar&#237;a A&#46; Estecha-Foncea&#46; Han contribuido en la recogida de datos los Dres&#46; Nicol&#225;s Zamboshi&#44; Carolina Rueda-Molina&#44; Victoria Doncel-Abad&#44; Ana I&#46; Molina- Ramos&#44; Imad Ben-Abdellatif&#44; Marina Gordillo-Resina y Esteban P&#233;rez-Mesa&#46; Las encuestas telef&#243;nicas fueron realizadas por las Dras&#46; Maria Nieto-Gonz&#225;lez&#44; Pilar Nuevo-Ortega y Carmen Reina-Artacho&#46; El an&#225;lisis estad&#237;stico de los datos fue realizado por los doctores Jorge Rodriguez-Capit&#225;n y Rafael J&#46; Jim&#233;nez-L&#243;pez&#46; El autor de correspondencia es el Dr&#46; Manuel F&#46; Jim&#233;nez-Navarro&#44; perteneciente al Instituto de Investigaci&#243;n Biom&#233;dica de M&#225;laga &#40;IBIMA&#41;&#44; Universidad de M&#225;laga &#40;UMA&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflicto de intereses</span><p id="par0245" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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    "fechaRecibido" => "2022-09-07"
    "fechaAceptado" => "2022-11-22"
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            0 => "COVID-19"
            1 => "Insuficiencia respiratoria"
            2 => "Ventilaci&#243;n mec&#225;nica"
            3 => "ONAF"
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            0 => "COVID-19"
            1 => "Respiratory failure"
            2 => "Mechanical ventilation"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objetivo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Describir las secuelas al mes del alta hospitalaria en pacientes que precisaron ingreso en Cuidados Intensivos por neumon&#237;a grave COVID-19 y analizar las diferencias entre los que recibieron terapia exclusivamente con oxigenoterapia con alto flujo con respecto a los que precisaron ventilaci&#243;n mec&#225;nica invasiva &#40;VMI&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Dise&#241;o</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Estudio de cohorte&#44; prospectivo y observacional&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">&#193;mbito</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Consulta multidisciplinar pos Cuidados Intensivos&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Pacientes o participantes</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Pacientes que superaron el ingreso en la Unidad de Cuidados Intensivos &#40;UCI&#41; por neumon&#237;a grave COVID-19 desde abril 2020 hasta octubre 2021&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Intervenciones</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Inclusi&#243;n</span> en el programa multidisciplinar pos UCI&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Variables de inter&#233;s principales</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Secuelas motoras&#44; sensitivas&#44; psicol&#243;gicas&#47;psiqui&#225;tricas&#44; respiratorias y nutricionales tras el ingreso hospitalario&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 104 pacientes&#46; 48 pacientes recibieron oxigenoterapia nasal de alto flujo &#40;ONAF&#41; y 56 VMI&#46; Las principales secuelas encontradas fueron la neuropat&#237;a distal &#40;33&#44;9&#37; VMI vs&#46; 10&#44;4&#37; ONAF&#41;&#59; plexopat&#237;a braquial &#40;10&#44;7&#37; VMI vs&#46; 0&#37; ONAF&#41;&#59; disminuci&#243;n de fuerza de agarre&#58; mano derecha 20&#44;67 kg &#40;&#177; 8&#44;27&#41; en VMI vs&#46; 31&#44;8 kg &#40;&#177; 11&#44;59&#41; en ONAF y mano izquierda 19&#44;39 kg &#40;&#177; 8&#44;45&#41; en VMI vs&#46; 30&#44;26 kg &#40;&#177; 12&#44;74&#41; en ONAF&#59; y balance muscular limitado en miembros inferiores &#40;28&#44;6&#37; VMI vs&#46; 8&#44;6&#37; ONAF&#41;&#46; Las diferencias observadas entre ambos grupos no alcanzaron significaci&#243;n estad&#237;stica en el estudio multivariable&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Los resultados obtenidos tras el estudio multivariable sugieren no existir diferencias en cuanto a las secuelas f&#237;sicas percibidas al mes del alta hospitalaria en funci&#243;n de la terapia respiratoria empleada&#44; ya fuera ONAF o ventilaci&#243;n mec&#225;nica prolongada&#44; si bien son precisos m&#225;s estudios para poder obtener conclusiones al respecto&#46;</p></span>"
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            "titulo" => "Dise&#241;o"
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          2 => array:2 [
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            "titulo" => "&#193;mbito"
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          3 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Pacientes o participantes"
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          4 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Intervenciones"
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          5 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Variables de inter&#233;s principales"
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            "titulo" => "Resultados"
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            "titulo" => "Conclusiones"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Objective</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">To describe the sequelae one month after hospital discharge in patients who required admission to intensive care for severe COVID-19 pneumonia and to analyze the differences between those who received therapy exclusively with high-flow oxygen therapy compared to those who required invasive mechanical ventilation&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Design</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Cohort&#44; prospective and observational study&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Setting</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Post-intensive care multidisciplinary program&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients or participants</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Patients who survived admission to the intensive care unit &#40;ICU&#41; for severe COVID-19 pneumonia from April 2020 to October 2021&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Interventions</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Inclusion in the post-ICU multidisciplinary program&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Main variables of interest</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Motor&#44; sensory&#44; psychological&#47;psychiatric&#44; respiratory and nutritional sequelae after hospital admission&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">One hundred and four patients were included&#46; 48 patients received high-flow nasal oxygen therapy &#40;ONAF&#41; and 56 invasive mechanical ventilation &#40;IMV&#41;&#46; The main sequelae found were distal neuropathy &#40;33&#46;9&#37; IMV vs&#46; 10&#46;4&#37; ONAF&#41;&#59; brachial plexopathy &#40;10&#46;7&#37; IMV vs&#46; 0&#37; ONAF&#41;&#59; decrease in grip strength&#58; right hand 20&#46;67 kg &#40;&#177; 8&#46;27&#41; in VMI vs&#46; 31&#46;8 kg &#40;&#177; 11&#46;59&#41; in ONAF and left hand 19&#46;39 kg &#40;&#177; 8&#46;45&#41; in VMI vs&#46; 30&#46;26 kg &#40;&#177; 12&#46;74&#41; in ONAF&#59; and limited muscle balance in the lower limbs &#40;28&#46;6&#37; VMI vs&#46; 8&#46;6&#37; ONAF&#41;&#46; The differences observed between both groups did not reach statistical significance in the multivariable study&#46;</p></span> <span id="abst0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">The results obtained after the multivariate study suggest that there are no differences in the perceived physical sequelae one month after hospital discharge depending on the respiratory therapy used&#44; whether it was high-flow nasal oxygen therapy or prolonged mechanical ventilation&#44; although more studies are needed to be able to draw conclusions&#46;</p></span>"
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            "titulo" => "Design"
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            "titulo" => "Setting"
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          3 => array:2 [
            "identificador" => "abst0065"
            "titulo" => "Patients or participants"
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          4 => array:2 [
            "identificador" => "abst0070"
            "titulo" => "Interventions"
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            "identificador" => "abst0075"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dislipemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">14 &#40;29&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8 &#40;32&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">H&#225;bito tab&#225;quico&#44; n &#40;&#37;&#41;</span></td><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No fumador&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">22 &#40;45&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fumador&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;6&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;1&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ex-fumador&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">23 &#40;47&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">23 &#40;41&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Antecedentes respiratorios&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8 &#40;16&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">15 &#40;26&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;669&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>EPOC&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 &#40;2&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;3&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Asma&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;6&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;10&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>SAOS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;8&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 &#40;12&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Enfermedad renal&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;712&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Antecedentes cardiol&#243;gicos&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;12&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5 &#40;8&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;555&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cardiopat&#237;a isqu&#233;mica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;4&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;5&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Arritmias&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;4&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;1&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Valvulopat&#237;as&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;1&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Otros&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Antecedentes ortop&#233;dicos&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;6&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5 &#40;8&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;447&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fracturas previas&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;2&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;5&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Artritis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">85&#44;57 &#40;17&#44;61&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">90&#44;80 &#40;27&#44;49&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;389&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>FEV1&#44; media &#40;DE&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">87&#44;31 &#40;17&#44;99&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">89&#44;03 &#40;20&#44;22&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;724&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>FEV1&#47;FVC&#44; media &#40;DE&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">82&#44;34 &#40;8&#44;43&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">84&#44;16 &#40;15&#44;26&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">n &#61; 38&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">112&#44;10 &#40;33&#44;04&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pimax&#44; media &#40;DE&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pemax&#44; media &#40;DE&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">74&#44;12 &#40;25&#44;82&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#44;898&nbsp;\t\t\t\t\t\t\n
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          "es" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Pruebas funcionales&#58; Rehabilitaci&#243;n&#46; Test de la marcha y dinam&#243;metro de mano&#46; Pruebas funcionales respiratorias&#58; Espirometr&#237;a y presiones respiratorias</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Plexopat&#237;a braquial</th></tr><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">OR &#40;IC 95&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Kilos perdidos UCI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Pronos&nbsp;\t\t\t\t\t\t\n
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                  """
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                  <table border="0" frame="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">OR &#40;IC 95&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Edad&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;208&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#44;986 &#40;0&#44;943-1&#44;030&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;515&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Pronos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;248 &#40;0&#44;888-1&#44;755&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;202&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">ONAF&#47;VMI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#44;417 &#40;0&#44;334-17&#44;504&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;385&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">OR &#40;IC 95&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Traqueostom&#237;a&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#44;988 &#40;0&#44;923-69&#44;107&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Kilos perdidos UCI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;088 &#40;0&#44;988-1&#44;198&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;088&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;850 &#40;0&#44;701-1&#44;031&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#44;100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">D&#237;as ingreso hospitalario&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;016 &#40;0&#44;995-1&#44;037&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;127&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">D&#237;as VM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;126 &#40;0&#44;949-1&#44;336&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;153 &#40;0&#44;819-1&#44;624&#41;&nbsp;\t\t\t\t\t\t\n
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          "es" => "<p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis multivariable factores de riesgo asociados a plexopat&#237;a braquial &#40;A&#41;&#44; balance muscular limitado miembros inferiores &#40;B&#41; y neuropat&#237;a distal &#40;C&#41;</p>"
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                    0 => array:2 [
                      "titulo" => "Recomendaciones para el manejo de los pacientes cr&#237;ticos con COVID-19 en las Unidades de Cuidados Intensivos"
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                      "titulo" => "Successive prone positioning sessions in mechanically ventilated patients with moderate and severe acute respiratory distress syndrome secondary to COVID-19&#58; case series"
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                            3 => "A&#46;F&#46; Costa"
                            4 => "B&#46;Y&#46; Recalde"
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                      "titulo" => "Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection&#58; A cross-sectional evaluation"
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