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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">En los &#250;ltimos 10 a&#241;os han surgido muchas recomendaciones para la atenci&#243;n al final de la vida de pacientes con enfermedad respiratoria avanzada&#44; apoyando el soporte de pacientes respiratorios cr&#243;nicos con programas de cuidados paliativos de forma precoz&#44; no basada en la identificaci&#243;n de la muerte inminente&#44; sino en fases anteriores de la enfermedad y de forma simult&#225;nea con tratamientos curativos<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; Sin embargo&#44; la dificultad para identificar a pacientes candidatos por la ausencia de criterios predictores de mortalidad a corto plazo&#44; junto con la dificultad de coordinaci&#243;n y comunicaci&#243;n entre niveles asistenciales ha llevado a la falta de traducci&#243;n en la pr&#225;ctica cl&#237;nica habitual&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">En nuestra comunidad se ha desarrollado un Plan de cuidados paliativos&#44; con el objetivo de ofrecer una atenci&#243;n de calidad paliativa a todas las personas con patolog&#237;a oncol&#243;gica y no oncol&#243;gica&#44; y en todos los &#225;mbitos asistenciales<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">En los pacientes con enfermedad respiratoria avanzada&#44; la afectaci&#243;n de la calidad de vida&#44; la ansiedad-depresi&#243;n y la presencia de s&#237;ntomas invalidantes como astenia y disnea son tan prevalentes como en los pacientes con c&#225;ncer&#44; sin embargo&#44; los pacientes oncol&#243;gicos reciben atenci&#243;n paliativa en un 60-47&#37; de los casos&#44; mientras que los pacientes con enfermedad respiratoria avanzada solo en un 1&#44;5-20&#37;&#44; y con una mayor demora a la hora de la inclusi&#243;n en programas de cuidados paliativos&#46; Se ha demostrado que la identificaci&#243;n temprana y el manejo multidimensional de pacientes con necesidades paliativas ofrece un claro beneficio en t&#233;rminos de control sintom&#225;tico y calidad de vida<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">4&#8211;7</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">El primer instrumento dise&#241;ado para identificar pacientes en la comunidad con afecciones cr&#243;nicas avanzadas y necesidades de cuidados paliativos fue la herramienta <span class="elsevierStyleItalic">Gold Standards Framework Prognostic Indicator Guidance</span> &#40;GSF-PIG&#41;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">8</span></a>&#46; El instrumento NECPAL &#40;Necesidades Paliativas&#41; del Centro Colaborador de la OMS para Programas P&#250;blicos de Cuidados Paliativos-Instituto Catal&#225;n de Oncolog&#237;a &#40;CCOMS-ICO&#41;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">9&#44;10</span></a> es una adaptaci&#243;n de la GSF-PIG validada en Espa&#241;a para la identificaci&#243;n de personas en situaci&#243;n de enfermedad cr&#243;nica avanzada y necesidad de atenci&#243;n paliativa&#46; Se trata de una evaluaci&#243;n cuanti-cualitativa&#44; multifactorial&#44; que combina la percepci&#243;n del profesional &#40;pregunta sorpresa&#58; &#171;&#191;le sorprender&#237;a que este paciente fallezca en los pr&#243;ximos 12 meses&#63;&#187;&#41;&#44; con la demanda del paciente o familiares y con indicadores objetivos de gravedad y progresi&#243;n de la enfermedad&#44; comorbilidad y consumo de servicios&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Hay creciente evidencia de que la herramienta NECPAL es &#250;til para detectar individuos con enfermedades cr&#243;nicas avanzadas y necesidades de cuidados paliativos&#46; Esta herramienta ha sido testada en atenci&#243;n primaria&#44; para el <span class="elsevierStyleItalic">screening</span> de pacientes con necesidades paliativas&#44; encontrando un 1&#44;5&#37; de prevalencia estimada<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">11</span></a>&#46; Sin embargo&#44; son escasos los estudios evaluando prevalencia de pacientes con necesidades paliativas ingresados en hospitales de agudos y se trata de estudios brit&#225;nicos y australianos con sistemas de salud alejados del nuestro<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">12&#8211;14</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Por ello planteamos este estudio&#44; con el objetivo de conocer la prevalencia de pacientes con necesidades paliativas en una unidad de hospitalizaci&#243;n de agudos de Neumolog&#237;a de un hospital terciario&#44; utilizando la herramienta NECPAL&#46; Como objetivo secundario nos propusimos estimar la tasa de mortalidad en estos pacientes identificados como paliativos NECPAL positivos en los siguientes 12 meses y explorar los factores asociados a la mortalidad&#44; las caracter&#237;sticas de estos pacientes y los recursos utilizados&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Metodolog&#237;a</span><p id="par0040" class="elsevierStylePara elsevierViewall">Se trata de un estudio observacional descriptivo prospectivo&#44; unic&#233;ntrico&#44; con un a&#241;o de seguimiento&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Poblaci&#243;n a estudio&#58; Se incluyeron todos los pacientes mayores de 18 a&#241;os ingresados m&#225;s de tres d&#237;as en fechas predeterminadas &#40;un d&#237;a al mes durante 12 meses consecutivos&#44; entre junio del 2017 y mayo del 2018&#41;&#44; en la planta de Neumolog&#237;a del Hospital de Cruces &#40;un hospital de agudos terciario&#41;&#46; Se excluyeron los pacientes que hab&#237;an sido incluidos en un ingreso anterior o que no aceptaron participar en el estudio&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">La variable principal del estudio trasversal fue la tasa de pacientes considerados como NECPAL CCOMS-ICO positivos&#44; aquellos en los que la respuesta a la primera pregunta&#58; &#171;&#191;le sorprender&#237;a que su paciente falleciera en 12 meses&#63;&#187; Es No junto con al menos otro criterio positivo<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">9</span></a>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Como variable secundaria del estudio se evalu&#243; la mortalidad a los 12 meses para calcular el valor predictivo de la herramienta&#46; Se analizaron datos demogr&#225;ficos y todas las variables recogidas en el instrumento NECPAL&#44; incluyendo valoraci&#243;n de dependencia para actividades de la vida diaria &#40;&#237;ndice de Barthel&#41;&#44; detecci&#243;n de malestar emocional &#40;escala DME&#41; y disnea seg&#250;n la escala modificada MRC&#59; se recogieron tambi&#233;n enfermedades asociadas &#40;&#237;ndice de Charlson&#41;&#44; diagn&#243;stico principal en el ingreso y datos funcionales respiratorios &#40;espirometr&#237;a y gasometr&#237;a&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Una vez que se asegur&#243; el cumplimiento de los criterios de inclusi&#243;n&#44; se cumpliment&#243; la herramienta NECPAL junto con el cl&#237;nico responsable&#46; Si el paciente se identific&#243; como paliativo se realiz&#243; seguimiento telef&#243;nico &#40;o a familiares&#41; cada tres meses&#44; sin modificar el seguimiento cl&#237;nico habitual&#46; Se analiz&#243; en la historia cl&#237;nica electr&#243;nica el uso de recursos sanitarios en los siguientes 12 meses &#40;n&#250;mero de ingresos&#44; d&#237;as ingresados&#44; lugar de ingreso y visitas a urgencias&#41;&#44; existencia de identificaci&#243;n como paliativo en historia cl&#237;nica&#44; uso de opi&#225;ceos pautados &#40;excluyendo las &#250;ltimas 48 horas de vida&#41; y registro de atenci&#243;n psicol&#243;gica en historia cl&#237;nica&#46; Se cre&#243; una base de datos anonimizada y encriptada espec&#237;fica para el proyecto que cumpli&#243; los requisitos legales de confidencialidad y fue aprobado por el CEIC del centro&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">An&#225;lisis estad&#237;stico</span><p id="par0065" class="elsevierStylePara elsevierViewall">Se realiz&#243; un c&#225;lculo de tama&#241;o muestral para una prevalencia esperada de 27&#37;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">12</span></a> para un nivel de confianza del 95&#37;&#44; asumiendo una precisi&#243;n del 5&#37;&#44; siendo necesaria una muestra de 302 pacientes&#46; Las variables continuas se expresaron como media &#40;desviaci&#243;n est&#225;ndar&#41; en caso de seguir una distribuci&#243;n normal o mediana &#40;rango intercuartil&#41; en caso contrario&#46; Las variables categ&#243;ricas se presentaron como frecuencia &#40;porcentaje&#41;&#46; Para la identificaci&#243;n de variables predictoras de mortalidad se realiz&#243; un an&#225;lisis bivariado&#46; Se compararon los factores sociodemogr&#225;ficos y cl&#237;nicos basales entre ambos grupos mediante el test <span class="elsevierStyleItalic">t</span> de Student&#44; en el caso de las variables continuas que segu&#237;an una distribuci&#243;n normal&#44; o el test no param&#233;trico U de Mann-Whitney en caso contrario&#46; Para las variables categ&#243;ricas se us&#243; el test de &#967;<span class="elsevierStyleSup">2</span>&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Se realiz&#243; el an&#225;lisis multivariante mediante modelos de regresi&#243;n de Cox&#44; incluyendo como variables predictoras aquellas que salieron significativas en el an&#225;lisis bivariado&#46; Se realizaron curvas de Kaplan-Meier&#46; Se consider&#243; que hab&#237;a diferencias estad&#237;sticamente significativas cuando p &#60; 0&#44;05&#46; Todos los an&#225;lisis se realizaron mediante el <span class="elsevierStyleItalic">software</span> estad&#237;stico R &#40;versi&#243;n 4&#46;0&#46;1 R&#58; A language and environment for statistical computing&#46; R Foundation for Statistical Computing&#44; Vienna&#44; Austria&#46;&#41;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="par0075" class="elsevierStylePara elsevierViewall">Se analizaron 363 pacientes&#46; De ellos&#44; 87&#44; un 24&#44;3&#37; &#40;IC 95&#37;&#58; 19-30&#41;&#44; fueron identificados como NECPAL positivos con necesidades paliativas&#46; Las caracter&#237;sticas basales de los pacientes se muestran en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46; La <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a> muestra la descripci&#243;n de los resultados de las variables recogidas en el instrumento NECPAL&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Durante el seguimiento de 12 meses fallecieron 54 pacientes NECPAL positivos&#44; un 60&#37;&#46; La mediana de supervivencia fue de 10 meses&#44; IC 95&#37;&#58; 6-23 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; No hubo ninguna p&#233;rdida en el seguimiento&#46; La mortalidad de los pacientes NECPAL negativos al a&#241;o fue del 11&#37;&#46; No hubo diferencias en mortalidad entre pacientes con diagn&#243;stico oncol&#243;gico y no oncol&#243;gico&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a> se muestran los datos del an&#225;lisis univariante&#46; Cuando se realiza un an&#225;lisis multivariante&#44; se obtiene una asociaci&#243;n significativa de la demanda de tratamiento paliativo del paciente o la familia con la mortalidad del paciente&#44; y tambi&#233;n cuando el indicador espec&#237;fico de progresi&#243;n de la enfermedad respiratoria es positivo &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Respecto al lugar de fallecimiento&#44; 25 pacientes &#40;46&#37;&#41; fallecieron en hospitales de agudos&#44; 16 en centros de media estancia &#40;30&#37;&#41;&#44; y solo 13 pacientes &#40;24&#37;&#41; falleci&#243; en su domicilio o en residencia&#46; Solo el 5&#44;7&#37; de los pacientes hab&#237;an sido codificados al inicio del estudio como paliativos en su historia cl&#237;nica &#40;cinco pacientes&#41;&#44; al final de los 12 meses del seguimiento&#44; este porcentaje subi&#243; a 34&#37; &#40;30 pacientes&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discusi&#243;n</span><p id="par0090" class="elsevierStylePara elsevierViewall">La tasa de pacientes con necesidades paliativas identificados con la herramienta NECPAL en nuestra planta de neumolog&#237;a ha sido del 24&#37;&#46; Aunque hasta la fecha no existen datos de prevalencia en pacientes exclusivamente respiratorios&#44; esta proporci&#243;n ha sido muy similar a la descrita en otros entornos en hospitales de agudos en global&#44; en los que no se ha discriminado por tipo de patolog&#237;a y en los que los que los resultados var&#237;an entre el 19-27&#37; encontrado en Nueva Zelanda y Australia&#44; y el 36&#37; en dos hospitales de Reino Unido<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">12&#8211;14</span></a>&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">En otras patolog&#237;as avanzadas de un &#243;rgano&#44; no neopl&#225;sicas&#44; los datos son m&#225;s dispares&#44; por ejemplo&#44; en el caso de la cirrosis&#44; hasta el 83&#37; de los pacientes que ingresan en una unidad de agudos portuguesa cumplen criterios de necesidades paliativas<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">15</span></a>&#44; mientras que en pacientes ingresados con s&#237;ndrome coronario agudo se describe entre un 8 y un 23&#37; con necesidades paliativas<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">16&#8211;17</span></a>&#46; En nuestro pa&#237;s&#44; un estudio multic&#233;ntrico en pacientes ambulatorios seguidos en consultas monogr&#225;ficas de insuficiencia cardiaca encuentra un 32&#37; de pacientes con NECPAL positivos<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">18</span></a>&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">En nuestra serie&#44; los diagn&#243;sticos principales m&#225;s frecuentes de los pacientes con necesidades paliativas han sido la EPOC&#44; seguido de la patolog&#237;a oncol&#243;gica&#46; Adem&#225;s&#44; destaca que todav&#237;a sigue siendo mayor el uso de opioides en pacientes con c&#225;ncer respecto a otras patolog&#237;as no oncol&#243;gicas&#44; tambi&#233;n con un alto nivel de carga sintom&#225;tica y de disnea<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">19</span></a>&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Respecto a la mortalidad al a&#241;o de los pacientes identificados como paliativos&#44; la variable principal en el seguimiento&#44; es de un 60&#37;&#59; una mortalidad similar a la que se encuentra en otras cohortes de pacientes identificados como paliativos en hospitales de agudos<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">12&#8211;13</span></a>&#44; a pesar de que la herramienta NECPAL no fue dise&#241;ada para predecir mortalidad&#46; En un peque&#241;o trabajo realizado en pacientes respiratorios con necesidades paliativas de nuestro pa&#237;s&#44; identificados con otra metodolog&#237;a&#44; la mortalidad es similar<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">20</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">En los trabajos realizados en atenci&#243;n primaria&#44; la mortalidad de los pacientes NECPAL positivos es claramente inferior&#44; en torno al 45&#37;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">10</span></a>&#46; En los pacientes con insuficiencia cardiaca&#44; identificados como paliativos en una consulta monogr&#225;fica ambulatoria&#44; se ha observado una tasa de mortalidad al a&#241;o del 21&#37;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">18</span></a>&#44; probablemente debido a que la hospitalizaci&#243;n por s&#237; misma indica mayor severidad&#44; lo que subraya el papel pron&#243;stico de los ingresos hospitalarios&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">En una revisi&#243;n sistem&#225;tica de 17 estudios que analizan el valor predictivo de mortalidad de la pregunta sorpresa de forma aislada&#44; los autores concluyen que muestra un valor predictivo peor en pacientes no oncol&#243;gicos<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">21</span></a>&#46; Sin embargo&#44; en nuestros datos no encontramos diferencias de mortalidad al a&#241;o entre los distintos diagn&#243;sticos de base&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">En el an&#225;lisis univariante&#44; el uso de opi&#225;ceos y la presencia de dos o m&#225;s criterios NECPAL se asocian a mayor mortalidad&#46; Sin embargo&#44; al realizar un an&#225;lisis multivariante de factores asociados a mortalidad&#44; las variables mencionadas pierden peso&#44; y solo aparecen con valor predictivo significativo la demanda de atenci&#243;n paliativa por parte de paciente o familiares y la presencia de indicador espec&#237;fico de progresi&#243;n de enfermedad respiratoria&#44; que incluye la presencia de al menos dos de los siguientes criterios&#58; disnea a m&#237;nimos esfuerzos&#44; FEV1 &#60; 30&#37; o DLCO &#60; 40&#37;&#44; oxigenoterapia domiciliaria&#44; insuficiencia cardiaca asociada o m&#225;s de dos ingresos en el a&#241;o previo&#46; Sorprende en nuestros datos que otros factores como la edad o el &#237;ndice de Charlson cl&#225;sicamente considerados como predictores de mortalidad no aparecen como significativos&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">El valor pron&#243;stico de la demanda de cuidados paliativos del paciente o familiares sugiere que debe ser un criterio importante a tener en cuenta a la hora de iniciar un abordaje paliativo del paciente&#44; sin que esto signifique abandonar otros tratamientos&#46; Esta conclusi&#243;n se encuentra en la l&#237;nea de revisiones recientes en EPOC que muestran que ninguno de los criterios pron&#243;sticos de mortalidad propuestos hasta ahora ofrece suficiente validez a corto o medio plazo&#44; por lo que la decisi&#243;n de iniciar cuidados paliativos debe basarse en la existencia de s&#237;ntomas refractarios y la demanda de los pacientes<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">22</span></a>&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">La identificaci&#243;n de estos pacientes en la historia cl&#237;nica como paliativos&#44; un elemento importante para la comunicaci&#243;n entre niveles asistenciales&#44; en nuestra serie ha sido baja&#46; Muy pocos pacientes estaban identificados al inicio del estudio&#44; aunque los datos mejoran a lo largo del a&#241;o de seguimiento&#44; con un 34&#37; al final del estudio&#46; Esta identificaci&#243;n como paciente con necesidades paliativas no implica de ninguna manera el abandono del tratamiento &#243;ptimo basado en la evidencia proporcionado durante su ingreso&#44; sino que consiste en recibir un soporte extra para sus necesidades&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Consideramos que son necesarios formaci&#243;n y recursos para atender a estos pacientes&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Limitaciones de este estudio&#58; los datos recogidos pertenecen a un solo hospital en un sistema sanitario concreto&#44; lo que dificulta su generalizaci&#243;n&#46; Para evitar sesgos de selecci&#243;n se incluyeron todos los pacientes ingresados m&#225;s de tres d&#237;as&#44; en fechas predeterminadas de todos los meses del a&#241;o&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusiones</span><p id="par0145" class="elsevierStylePara elsevierViewall">La prevalencia de pacientes con necesidades paliativas en una planta de Neumolog&#237;a de un hospital de agudos es alta &#40;uno de cada cuatro pacientes&#41;&#46; De ellos&#44; el 60&#37; fallece en los siguientes 12 meses&#46; La valoraci&#243;n de pacientes respiratorios ingresados debe incluir elementos como la pregunta sorpresa&#44; las demandas del paciente&#44; adem&#225;s de criterios espec&#237;ficos de progresi&#243;n de la enfermedad respiratoria&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflicto de intereses</span><p id="par0150" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introducci&#243;n</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El instrumento NECPAL es una herramienta para la identificaci&#243;n de personas en situaci&#243;n de enfermedad cr&#243;nica avanzada con necesidades paliativas&#46; El objetivo del estudio es conocer la prevalencia de pacientes con necesidades paliativas en un Servicio de Neumolog&#237;a de un hospital terciario mediante la herramienta NECPAL&#46; Como objetivo secundario se plantea conocer la mortalidad al a&#241;o de estos pacientes&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Material y m&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Estudio trasversal y seguimiento prospectivo de la cohorte de los pacientes identificados como paliativos con la herramienta NECPAL durante 12 meses&#46; La identificaci&#243;n se realiza en pacientes ingresados &#62; 3 d&#237;as en una planta de Neumolog&#237;a&#46; Hemos evaluado el estatus vital &#40;fallecido o no fallecido&#41; al a&#241;o&#44; as&#237; como datos demogr&#225;ficos cl&#237;nicos&#44; funcionales y uso de recursos sanitarios&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Se analizaron 363 pacientes&#46; De ellos&#44; 87 &#40;24&#44;3&#37;&#41; &#40;IC 95&#37;&#44; 19-30&#41; fueron identificados como NECPAL positivos&#46; En el seguimiento durante un a&#241;o fallecieron 54 pacientes&#44; un 60&#37;&#46; No hubo diferencias en mortalidad entre diagn&#243;sticos oncol&#243;gicos y no oncol&#243;gicos&#46; En el an&#225;lisis multivariante&#44; la mortalidad se asoci&#243; a la demanda de paciente o familiares de atenci&#243;n paliativa y a la presencia de indicadores espec&#237;ficos de progresi&#243;n de la enfermedad&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusiones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La prevalencia de pacientes con necesidades paliativas en una planta de hospitalizaci&#243;n de agudos de Neumolog&#237;a es alta &#40;uno de cada cuatro pacientes&#41;&#46; El 60&#37; de los identificados como NECPAL positivos en nuestra serie fallece en los primeros 12 meses&#46; Son necesarios formaci&#243;n y recursos para atender a estos pacientes&#46;</p></span>"
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            "titulo" => "Material y m&#233;todos"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introduction</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">NECPAL is a tool for identification of patients with advanced chronic disease in need of palliative care&#46; The main objective of the study is to know the prevalence of patients with palliative needs in an acute respiratory ward in a Spanish tertiary hospital using NECPAL&#46; A second objective of the study is to know the annual mortality rate of these patients&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Materials and Methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Cross sectional study and prospective monitoring of a cohort identified as palliative patients with the NECPAL tool for 12 months&#46; Patient identification was performed in patients admitted to the respiratory ward of our hospital for longer than 3 days&#46; We have assessed the annual vital status &#40;deceased or not deceased&#41; of patients and have recorded demographics&#44; clinical and functional data&#44; as well as the use of healthcare resources&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">We monitored a cohort of 363 patients&#46; Of them&#44; 87 patients &#40;24&#46;3&#37;&#41; &#40;IC 95&#37; 19-30&#41; were identified as NECPAL positive&#46; 60&#37; of patients &#40;n &#61; 64&#41; died within 12 months of their admission&#46; There was no significant difference in the mortality ratio of oncologic versus non oncologic patients&#46; In a multivariable analysis&#44; mortality was associated with demand by patients or relatives for palliative care and with the presence of specific disease progression markers or indicators&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">prevalence of patients with palliative needs in acute respiratory wards is high &#40;one out of four patients&#41;&#46; 60&#37; of the patients identified as NECPAL positive in our cohort died in the first 12 months&#46; Training of healthcare professionals as well as availability of appropriate resources are indispensable factors to improve care of this population&#46;</p></span>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Demencia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">S&#237;&#58; 20No&#58; 62</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Perdida de &#62; 2 actividades de la vida diaria o &#62; 30&#37; de Barthel&#47;Karnofsky</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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Marcadores de fragilidadSd geri&#225;tricos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ca&#237;das &#62; 2&#218;lceras por presi&#243;nDisfagiaSd confusional&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"> &#62; &#61; 2&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">S&#237;&#58; 36No&#58; 51&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Distr&#233;s emocionalS&#237;ntomas persistentes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dolor&#44; debilidad&#44; disnea refractarios</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">S&#237;&#58; 34No&#58; 53&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Multimorbilidad&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">S&#237;&#58; 75No&#58; 12&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">Uso de recursos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">S&#237;&#58; 50No&#58; 37&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">P4&#46; Indicadores espec&#237;ficos de progresi&#243;n de enfermedad respiratoria&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">FEV &#60; 20&#37;&#44; FVC o DLCO &#60; 40&#37;Cor pulmonaleOCD&#62; 2 ingresosDisnea a m&#237;nimos esfuerzos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">S&#237;&#58; 60No&#58; 27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t">75&#44;8 &#43;&#47;- 11&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">76&#44;8 &#40;11&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;0&#44;97&#59; 1&#44;02&#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">57 &#40;66&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">21 &#40;63&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">36 &#40;66&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12 &#40;36&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12 &#40;33&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;96 &#40;0&#44;54&#59; 1&#44;69&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;88&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Demanda de pacientes n &#40;&#37;&#41;</span></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
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34 &#40;39&#37;&#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">19 &#40;57&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">15 &#40;27&#37;&#41;&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">53 &#40;60&#37;&#41;&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">2&#44;18 &#40;1&#44;20&#59; 3&#44;97&#41;&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  " colspan="6" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Progresi&#243;n cl&#237;nica general n &#40;&#37;&#41;</span></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
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;11&#37;&#41;&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">7 &#40;13&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#205;ndice de Barthel&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">66 &#40;80&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27 &#40;93&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39 &#40;73&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;19&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;26&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;25 &#40;1&#44;22&#59; 4&#44;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Actividad f&#237;sica n &#40;&#37;&#41;</span></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
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No anda&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36 &#40;44&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;32&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27 &#40;50&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No sale de casa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 &#40;39&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#40;46&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;35&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;68 &#40;0&#44;38&#59; 1&#44;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;13&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Anda &#60; 2 h&#47;semana&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;73 &#40;0&#44;6&#59; 4&#44;95&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Anda &#62; 2 h&#47;semana&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;18&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;42 &#40;0&#44;13&#59; 1&#44;37&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Diagn&#243;stico n &#40;&#37;&#41;</span></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
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Oncol&#243;gico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;20&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;15&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;24&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No oncol&#243;gico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69 &#40;80&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;84&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&#40;76&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;55 &#40;0&#44;82&#59; 2&#44;97&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2573177.png"
              ]
            ]
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        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis de supervivencia univariado para la mortalidad&#46; Se muestran los hazard <span class="elsevierStyleItalic">ratio</span> &#40;HR&#41; con sus respectivos intervalos de confianza</p>"
        ]
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        "etiqueta" => "Tabla 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at4"
            "detalle" => "Tabla "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">HR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95&#37; CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p-valor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Edad&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;9&#59; 1&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;9&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sexo&#58; mujer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;7&#59; 2&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;4&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Demanda&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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