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Dream changes following initiation of efavirenz treatment
Cambios en la ensoñación tras el inicio de tratamiento con efavirenz
María Velascoa,
Corresponding author
mvelasco@fhalcorcon.es

Corresponding author.
, Juan Antonio Parejab, Juan Emilio Losaa, José Francisco Valverdec, Alfredo Espinosaa, Carlos Gujarroa
a Infectious Diseases Section, Internal Medicine, Hospital Universitario Fundación Alcorcón, España
b Neurology Unit, Hospital Universitario Fundación Alcorcón, España
c Microbiology Unit, Hospital Universitario Fundación Alcorcón, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Efavirenz is a potent antiretroviral drug for HIV infection but neuropsychological toxicity is reported in around 20 to 50&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> One of the most common effects reported is sleeping disturbances including nightmares and vivid dreams&#46; There have been quantitative studies reported on the influence of efavirenz on sleep architecture&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> In most studies&#44; a questionnaire performed after the night of the study was used to assess dream changes&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> Retrospective self-reports significantly underestimate current nightmare and bad dream frequency when compared to other methods&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Qualitative studies focusing on the possible impact of efavirenz on dream content are lacking&#46; We endeavoured to assess the possible influence of efavirenz treatment on the length of dreams&#44; the thematic of the oniric scenes and the emotional content of dreams&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Patients and method</span><p id="par0010" class="elsevierStylePara elsevierViewall">This was a pilot study&#46; Ten HIV patients currently on follow-up in our clinic who consecutively started efavirenz treatment were studied before and after starting efavirenz treatment&#59; thus&#44; they were their own controls&#44; a previously used design&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Inclusion criteria were to be older than 18 years&#44; to start efavirenz treatment for any reason and to signed informed consent form&#46; Exclusion criteria were patients with previously known psychiatric disorders or psychiatric treatment&#44; any neurological disorder that could influence dreaming and sleep alterations&#46; The Ethical Hospital Institutional Committee Board approved the study&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Clinical and epidemiological variables were taken into account&#46; All the patients fulfilled a structured questionnaire designed by one of the authors &#40;JAP&#41; as a general assessment of sleep disorders symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> A nocturnal polysomnogram &#40;PSG&#41; study was performed before starting efavirenz and within two weeks after treatment&#46; A blood sample was obtained just before the second polysomnographic study to assess efavirenz plasma levels&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The PSG was performed recording electroencephalogram&#44; electrocardiogram and continuous finger pulse oxymetry&#46; Sleep stages were scored visually according to standard criteria&#46; Standard methods of PSG recording and scoring were used and we used validated techniques previously used to evaluate dreaming&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">We intended to study dream content of both the first and last REM sleep periods&#58; The REM sleep period occurring after 5&#58;00 am was considered the last REM period&#46; We studied REM sleep because during such a sleep stage dreams are more frequently reported and remembered&#44; and dream content is more vivid and emotional&#44; whereas dreaming arising from other sleep stages tend to be formed by short&#44; fragmented oniric scenes&#46; Otherwise&#44; nightmares are acknowledged as a REM sleep processes&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In each study subjects were awakened by calling their names 5-10<span class="elsevierStyleHsp" style=""></span>minutes after the beginning of the first and last REM sleep periods&#46; Once fully awake&#44; subjects were asked&#58; &#8220;Were you dreaming&#63;&#8221;&#46; If so&#44; &#8220;could you please tell me what actually were you dreaming before I woke you up&#63;&#8221; Once the patient spontaneously related the content of the dream&#44; we asked again twice&#58; &#8220;Do you remember anything else&#63;&#8221;&#46; All the questions and responses were audio taped for later analysis&#46; After each awakening subjects were allowed to fall sleep again&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Reports&#44; when present&#44; were written and later analyzed by the investigators&#44; who were unaware if the PSG was performed before or after the efavirenz treatment&#46; To evaluate the measure of the length of the dream we counted the number of words and the number of thematic units&#46; A new thematic unit was considered if the setting&#44; the activity or the main character of the dream changed&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Emotional content of the dream were classified into four categories&#58; violent&#47;highly anxious&#44; moderately anxious&#44; pleasant and neutral&#46; Dreams were considered violent&#47;highly anxious whenever there was verbal or physical violence in the dream or when the subject reported an awful&#44; stressful or highly emotional situation&#46; When subjects upon awakening were not able to remember any details of the dream in spite of thinking that they had dreamt&#44; we considered no dream recall and number of words was scored as null&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">We compared the dream changes before and after efavirenz in each subject&#46; For statistical analysis we used the Wilcoxon Signed Ranks Test to compare type of emotional content&#44; Z-test &#40;proportions&#41; for overall emotional content&#44; T Test for repeated measures for number of thematic units and words&#44; Chi-squared or Fischer as appropriate for recall rate&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">Eighteen PSG were performed in ten patients&#59; 10 underwent the first PSG and 8 the second PSG&#46; Reasons for withdrawal during the 2&#176; PSG were an onset of severe diarrhoea and hospital admission in one patient and laboral reasons in the other &#40;he started a night work&#41;&#46; The results were essentially identical when the 2 patients with incomplete follow-up were excluded from the analysis&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Eight patients were male and two female&#46; Mean age was 38&#46;6 &#40;10&#46;9&#41; years&#46; Mean time from HIV diagnosis to antiretroviral treatment was 2&#46;4 &#40;4&#46;3&#41; years&#46; Only 2 patients had received previous HAART without efavirenz&#44; and their mean time on HAART before efavirenz use was 1&#46;04 &#40;2&#46;2&#41; years &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Mean CD4 cells at baseline was 247&#46; 1 &#40;SD 167&#46;1&#41; c&#47;mL&#44; and viral load 5&#46;0 &#40;SD 1&#46;6&#41; lg10 cp&#47;mL&#46; No patients were taking neuropsychiatric drugs and no one had previous sleeping abnormalities&#46; Mean time on efavirenz treatment at the 2&#176; PSG was 10&#46;4 &#40;5&#46;4&#41; days&#46; Plasma levels of efavirenz extracted just before the PSG study were within therapeutic range in all the patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">After efavirenz treatment&#44; several symptoms were self-reported by the patients&#58; 4 of them reported anxiety&#44; 2 impaired concentration&#44; 1 diurnal somnolence and 1 insomnia&#46; Sleeping disturbances were self reported in 3 patients&#46; No patient had depressive symptoms&#46; Patient number 7 suffered a self limited acute confusional syndrome one day after starting efavirenz treatment&#46; Efavirenz was not stopped and the patient fully recovered in the following 48<span class="elsevierStyleHsp" style=""></span>hours&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">PSG were essentially normal in all the subjects&#44; apart from the two provoked interruptions to ask patients for their dreams&#46; Nine patients recalled at least one dream in the baseline study when awakened in REM sleep&#46; One patient reported dreaming only the first night and six patients reported dreaming both nights&#46; No patient reported dreams only the second night&#46; There were 16 dream reports in baseline night &#40;ten patients&#41; and 6 in second night &#40;eight patients&#41;&#46; Dreams were recalled in 16 out of 19 &#40;84&#37;&#41; awakenings in the patients without treatment&#44; and in 6 out of 14 awakenings &#40;43&#37;&#41; in the patients with efavirenz treatment &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;024&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Some patients recalled just one dream&#58; 2 in the first night and 4 patients in the second night&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">There were no differences in the mean number of words per dream before and after efavirenz treatment &#40;61&#46;9 <span class="elsevierStyleItalic">versus</span> 47&#46;5&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;115&#41; but the number of thematic units was higher before efavirenz than after &#40;16 <span class="elsevierStyleItalic">versus</span> 8&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;442&#41;&#46; Emotional content is described in detail in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; The proportion of dreams with no neutral emotional content &#40;either pleasant or unpleasant&#41; was higher after efavirenz treatment&#58; 37&#46;5&#37; in the first night and 66&#46;7&#37; in the second night&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">In this study&#44; surprisingly&#44; we have not found relevant abnormalities in dream patterns in patients taking efavirenz&#46; It is conceivable that the higher proportion of emotional dreams after efavirenz treatment underlies the perception of the effects of efavirenz on dream quality&#46; The artificial awakening in the laboratory of the present study has undercovered a substantial number of &#8220;neutral&#8221; dreams that may have been unnoticed in other studies&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Neuropsychiatric side effects of efavirenz may be related to its plasma levels&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In our series&#44; levels of efavirenz were within the therapeutical range in all patients&#44; showing that the drug was present at the moment of the PSG study&#46; Besides that&#44; none of our patients had prior neuropsychiatric abnormalities&#44; which may explain the absence of major dreams changes&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">An obvious limitation of our work is the small size and the possibility of a result by chance&#46; This series may be underpowered to detect significant changes in dream pattern&#46; Other reports on sleep abnormalities after efavirenz treatment evaluated by PSG have explored 10 or 18 patients&#44; a number very similar to our study&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> The withdrawal adds a difficult to the correct interpretation of the data&#46; However&#44; repeated analysis without withdrawals showed similar results&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In conclusion&#44; in spite of the common belief that efavirenz increases dream production&#44; dream recall and length of dreams were lower after efavirenz treatment&#46; The perception of a higher dream production may be due to the lower percentage of dreams with neutral emotional content&#46; Our data suggest that dream changes after efavirenz treatment are more complex than usually considered&#46; Further research may shed light in the complex effects of efavirenz in dreams&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that they do not have competing interests&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The study was supported by Bristol-Myers Squibb&#46; BMS had no role in the design&#44; analysis&#44; or interpretation of the study&#46;</p></span></span>"
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          "titulo" => array:5 [
            0 => "Resumen"
            1 => "Fundamento y objetivo"
            2 => "Pacientes y m&#233;todo"
            3 => "Resultados"
            4 => "Conclusiones"
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec93540"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Patients and method"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Results"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Discussion"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Conflict of interest"
        ]
        9 => array:2 [
          "identificador" => "xack36019"
          "titulo" => "Acknowledgements"
        ]
        10 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2010-01-21"
    "fechaAceptado" => "2010-06-17"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec93539"
          "palabras" => array:4 [
            0 => "Dreams"
            1 => "Efavirenz"
            2 => "HIV infection"
            3 => "Adverse effects"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec93540"
          "palabras" => array:4 [
            0 => "Sue&#241;os"
            1 => "Efavirenz"
            2 => "Infecci&#243;n por VIH"
            3 => "Efectos adversos"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Background and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The objective was to evaluate abnormalities in the quality of dreams after the use of efavirenz&#46;</p> <span class="elsevierStyleSectionTitle">Patients and method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Ten HIV patients without neuropsychiatric diseases underwent a polisomnography &#40;PSG&#41; study before and after efavirenz treatment&#44; &#91;after 10&#46;4 &#40;SD 5&#46;4&#41; days&#93;&#46; Patients were awoke after REM phases to record their dreams&#46; All patients had therapeutic efavirenz plasma levels&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Dreams were recalled in 84&#37; before efavirenz and 43&#37; after efavirenz &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;024&#41;&#46; There were no differences in the mean number of words per dream before and after efavirenz treatment &#40;61&#46;9 versus 47&#46;5&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;115&#41;&#46; The proportion of dreams with no neutral emotional content &#40;either pleasant or unpleasant&#41; was 37&#46;5&#37; in the first night and 66&#46;7&#37; in the second night &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;046&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">There were a higher proportion of dreams with no neutral emotional content after efavirenz treatment in this group of patients&#46; However&#44; no longer dreams and no more dreams with negative emotional content were noted&#46; Dream recall was lower after efavirenz treatment&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Fundamento y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El objetivo del presente trabajo fue evaluar las alteraciones en la calidad de la enso&#241;aci&#243;n tras el inicio de efavirenz&#46;</p> <span class="elsevierStyleSectionTitle">Pacientes y m&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; una polisomnograf&#237;a &#40;PSG&#41; a diez pacientes sin antecedentes neurosiqui&#225;tricos antes y despu&#233;s del tratamiento con efavirenz &#40;10&#44;4 &#91;DS 5&#46;4&#93; d&#237;as despu&#233;s&#41;&#44; y se despert&#243; a los pacientes en fase REM para grabar la enso&#241;aci&#243;n&#46; Todos los pacientes ten&#237;an niveles plasm&#225;ticos terap&#233;uticos de efavirenz antes de la PSG&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Los pacientes recordaron alg&#250;n tipo de enso&#241;aci&#243;n en el 84&#37; de las veces antes del tratamiento con efavirenz&#44; mientras que despu&#233;s del tratamiento s&#243;lo fue el 43&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;024&#41;&#46; No hubo diferencias en el n&#250;mero medio de palabras por sue&#241;o antes y despu&#233;s del tratamiento con efavirenz &#40;61&#44;96 versus 47&#44;5&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;115&#41;&#46; La proporci&#243;n de sue&#241;os con contenido emocional no neutro &#40;agradable o desagradable&#41; fue 37&#44;5&#37; antes de efavirenz y 66&#44;7&#37; despu&#233;s &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;046&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Tras el tratamiento con efavirenz disminuye la enso&#241;aci&#243;n con contenido neutro&#44; pero no aumenta ni la duraci&#243;n ni el contenido emocional negativo de la enso&#241;aci&#243;n&#46; Adem&#225;s&#44; no hubo sue&#241;os m&#225;s largos y la tasa de recuerdo de la enso&#241;aci&#243;n fue menor&#46;</p>"
      ]
    ]
    "multimedia" => array:2 [
      0 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Level 1-4<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;mL is the therapeutic range of efavirenz plasma levels&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">D4T&#58; stavudine&#59; EFV&#58; efavirenz&#59; TDF&#58; tenofovir&#59; ZDV&#58; zidovudine&#59; 3TC&#58; lamivudine&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Patient number&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Days on efavirenz treatment at 2&#176; PSG&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Plasma levels efavirenz &#40;1-4<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;ml&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">d4T<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3TC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>EFV&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">ZDV<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3TC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>EFV&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;44&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">ZDV<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3TC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>EFV&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">ZDV<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3TC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>EFV&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">ZDV<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3TC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>EFV&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&#46;17&nbsp;\t\t\t\t\t\t\n
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                  """
              ]
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                0 => "xTab191810.png"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Moderately anxious&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&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&#46;024<span class="elsevierStyleSup">&#8225;</span>&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"><span class="elsevierStyleItalic">Number of thematic units</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&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">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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&#46;442<span class="elsevierStyleSup">&#35;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Number of words &#40;length of dreams&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&#46;9 &#40;47&#46;0&#41; median 54 &#40;IQ 21&#46;5-87&#46;0&#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
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47&#46;5 &#40;49&#46;1&#41; median 30 &#40;IQ 11&#46;75-68&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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        "texto" => "<p id="par0100" class="elsevierStylePara elsevierViewall">We thank Dr J Santamaria for critically reviewing the manuscript&#46;</p> <p id="par0105" class="elsevierStylePara elsevierViewall">Our acknowledgements to nurse and medical staff in Internal Medicine and Laboratory Units&#46;</p>"
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es en pt

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