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Original article
Quality of postoperative recovery after breast surgery. General anaesthesia combined with paravertebral versus serratus-intercostal block
Calidad de la recuperación posquirúrgica tras cirugía de mama. Anestesia general combinada con bloqueo paravertebral versus bloqueo del espacio serrato-intercostal
M.A. Pérez Herreroa,
Corresponding author
mapeherrero@gmail.com

Corresponding author.
, S. López Álvarezb, A. Fadrique Fuentesa, F. Manzano Loreficea, C. Bartolomé Bartoloméa, J. González de Záratea
a Hospital Clínico Universitario de Valladolid, Valladolid, Spain
b Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Breast cancer surgery is one of the most common procedures performed in developed countries&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> Conservative surgery&#44; which is just as effective but more aesthetically acceptable&#44; is now the most common approach&#46; Along with advances in surgical techniques&#44; spectacular progress has also been made in anaesthetic and analgesic management strategies that speed up recovery time and greatly improve post-operative well being&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">2&#8211;6</span></a> A wide variety of procedures and approaches to breast cancer surgery have been described in the literature&#44; including general&#44; locoregional&#44; and local anaesthesia&#44; and even intravenous lidocaine perfusion&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> Although there is no evidence to show the superiority of any of these over others&#44; most anaesthesiologists prefer combined techniques&#44; given the complex innervation of the breast&#44; the high rate of postoperative nausea and vomiting and acute and chronic pain&#44; and the potential association between opioids and the appearance of metastasis and tumour recurrence&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The regional technique of choice for the thorax is still the paravertebral block &#40;PVB&#41;&#46; This approach has been shown to provide the best analgesia with the lowest rate of cancer recurrence&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> Although the incidence of complications in PVB is low&#44; and can be reduced even further using ultrasound guidance&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a> very few anaesthesiologists are entirely confident using the technique&#46; Nevertheless&#44; since the 2011 study published by Blanco et al&#46;&#44; a number of ultrasound-guided interfascial nerve blocks using a peripheral instead of a paravertebral approach have been introduced&#46; These new techniques are equally effective&#44; but are safer and easier to perform&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">11&#44;12</span></a> One of the most important of these peripheral blocks is the intercostal branches block in the midaxillary line &#40;BRILMA&#44; in its Spanish acronym&#41;&#44; in which local anaesthetic is administered between the anterior serratus and external intercostal muscles&#46; However&#44; there is as yet insufficient evidence to support the effectiveness of this technique&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8&#44;12</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Technological advances&#44; such as the introduction of intravenous &#40;propofol and remifentanil&#41; and inhalation &#40;sevoflurane and desflurane&#41; anaesthetic agents with an almost ideal pharmacokinetic profile&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a> together with ultrasound-guided regional anaesthesia techniques<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">5&#44;7&#8211;12</span></a> and the use of laryngeal masks for airway management&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a> have improved both recovery rates and patient satisfaction&#44; and precluded the need for opioids&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">As a result of these new developments in surgical and anaesthetic techniques&#44; breast cancer surgery is increasingly being performed on an outpatient basis&#44; or with an overnight hospital stay&#46; In this new scenario&#44; anaesthesiologists need to exercise management skills&#44; and must maximise patient satisfaction while ensuring a high level of effectiveness and efficiency&#46; To achieve this&#44; indicators must be used to detect areas of improvement&#44; decide when the patient is ready for discharge&#44; and actively participate in follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The Postoperative Quality Recovery Scale &#40;PQRS&#41;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> has been validated to assess postoperative recovery&#46; The questionnaire uses 6 domains &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; to assess complete patient recovery&#46; It can be used to define immediate recovery&#44; and more importantly&#44; to establish when the patient is able to return to work&#44; which is the ultimate goal of routine medical practice&#46; As such&#44; the scale is a good indicator of quality&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Mindful of the importance of measuring recovery after breast surgery&#44; the primary objective of this study was to use the PQRS to quantify postoperative recovery from non-reconstructive breast surgery using general anaesthesia plus either PVB or BRILMA&#46; The secondary objective was to compare the 2 locoregional analgesia techniques used in terms of recovery&#44; and therefore safety&#44; in all PQRS domains&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">Following approval from the hospital&#39;s ethics committee &#40;authorisation no&#46; PI 15-328&#41;&#44; we conducted a prospective observational study over a period of 6 months&#46; Subjects were women scheduled for non-reconstructive breast surgery for cancer&#46; All subjects signed an informed consent form before taking part in the study&#46; The inclusion criteria were&#58; age &#8805;18 years&#44; body mass index &#60;25&#44; ASA physical status I&#8211;III and ability to understand and complete the PQRS questionnaire &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; and rate their pain from 0 to 10 on a numeric scale &#40;NRS&#41;&#46; Exclusion criteria were&#58; known difficult airway&#44; difficulty in evaluating pain or unable to complete the questionnaire&#44; allergy to any of the study drugs&#44; contraindicated for regional anaesthesia &#40;coagulation disorders&#44; infection or haematoma in the proximity of the puncture site&#41; or unwillingness to continue with the study&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">All patients received general anaesthesia and were randomised to the regional technique according to whether the date of their surgery fell on an even &#40;PVB group&#41; or uneven &#40;BRILMA&#41; date&#46; All patients completed the PQRS questionnaire &#40;baseline data&#41; before anaesthesia&#46; The locoregional block was performed prior to anaesthesia induction&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">A total of 60 patients were included in the study&#59; all nerve blocks were performed on awake patients&#44; using an ultrasound device &#40;Siemens Acuson P300&#8482;&#41; with a high frequency linear transducer &#40;6&#8211;15<span class="elsevierStyleHsp" style=""></span>MHz&#41;&#46; A Stimuplex<span class="elsevierStyleSup">&#174;</span> 22<span class="elsevierStyleHsp" style=""></span>G 100<span class="elsevierStyleHsp" style=""></span>mm needle &#40;B&#46; Braun Medical&#41; was used in the BRILMA group&#44; and a Touhy 22 G &#40;Perican<span class="elsevierStyleSup">&#174;</span>&#44; B&#46; Braun Medical&#41; in the PVB group&#46; Once the tip of the needle had been inserted and confirmed by negative aspiration&#44; 2<span class="elsevierStyleHsp" style=""></span>ml of local anaesthetic was instilled to confirm correct placement of the needle under ultrasound vision&#46; Following this&#44; up to 20<span class="elsevierStyleHsp" style=""></span>ml of 0&#46;25&#37; bupivaca&#237;ne was administered to patients in both groups&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Group PVB&#58; a sterile field was created and the patient was placed in a seated position&#46; The ultrasound transducer was positioned parallel to the spinal column and passed from cranial to caudal to locate thoracic vertebra T4&#46; Once this had been identified&#44; the transducer was placed horizontal to the spinal column to locate the paravertebral space ipsilateral to the breast of interest&#46; Once this had been identified&#44; the needle was inserted in plane from lateral to medial and advanced until it reached the paravertebral space&#44; where the anaesthetic was administered and observed to spread within the space &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">BRILMA group&#58; The patient was placed in a supine position&#44; with the arm ipsilateral to the breast of interest extended&#46; The transducer was placed along the midaxillary line and the needle was inserted in plane from a cranial to caudal direction and carefully advanced under observation to the space between the anterior serratus and external intercostal muscles&#46; Once it had been correctly positioned&#44; the anaesthetic was administered while observing the spread of the solution in the target area &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Both techniques were performed in the operating room following placement of a peripheral venous catheter&#44; and with the patient under 3-lead electrocardiogram&#44; non-invasive arterial pressure and peripheral arterial oxygen saturation monitoring&#46; None of the study patients received premedication&#46; After the corresponding locoregional nerve block had been administered&#44; propofol &#40;2&#8211;2&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41; was administered and hypnosis was monitored using a SedLine<span class="elsevierStyleSup">&#174;</span> sensor and Radical-7<span class="elsevierStyleSup">&#174;</span> hand held monitor &#40;Masimo&#44; Irvine&#44; CA&#44; USA&#41; until a Patient State Index score &#40;a numerical value obtained from 4 channels of encephalographic data&#41; of 30&#8211;40 had been achieved&#46; Following this&#44; a Supreme<span class="elsevierStyleSup">&#174;</span> laryngeal mask adjusted to the patient&#39;s weight was inserted&#46; Anaesthesia was maintained with propofol TCI &#40;2&#8211;5<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;ml&#41; and ventilation was adjusted to maintain normocapnia&#46; All patients received the same postoperative analgesia regimen&#58; 1<span class="elsevierStyleHsp" style=""></span>g intravenous paracetamol&#44; and 4<span class="elsevierStyleHsp" style=""></span>mg ondansetron 30<span class="elsevierStyleHsp" style=""></span>min before completion of surgery to prevent postoperative nausea and vomiting&#46; After completion of surgery and removal of the laryngeal mask&#44; the patients were transferred to the post anaesthesia care unit &#40;PACU&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The PQRS was administered again 15<span class="elsevierStyleHsp" style=""></span>min after transfer to the PACU&#46; Patients were transferred from the PACU to the ward when they reported no pain &#40;NPS score of less than 3&#41;&#44; no nausea&#44; and no other surgery-related complications&#46; Patients reporting pain were given 2<span class="elsevierStyleHsp" style=""></span>mg morphine hydrochloride every 5<span class="elsevierStyleHsp" style=""></span>min up to a maximum dose of 0&#46;15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg until an NPS score of &#60;3 was reported&#46; The day after surgery&#44; the patient was seen in the Breast Unit&#44; where the PQRS was administered again&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In all cases&#44; the questionnaire was administered by a trained nurse&#44; who also noted any additional analgesia required after surgery &#40;mg of morphine hydrochloride&#41;&#44; the onset of adverse effects&#44; such as postoperative nausea and&#47;or vomiting&#44; urinary retention&#44; somnolence&#44; the length of stay in the PACU&#44; and patient satisfaction &#40;rated as very satisfied&#44; satisfied&#44; neither satisfied nor dissatisfied&#44; dissatisfied&#41; at 24<span class="elsevierStyleHsp" style=""></span>h post surgery&#46; Complications related to the regional anaesthesia technique and difficulties encountered during administration were rated by the anaesthesiologist on a verbal scale &#40;easy&#44; rather difficult&#44; difficult&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">All patients followed up 1 month after the intervention&#44; at which time the PQRS was again administered in order to evaluate postoperative recovery&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Study variables were first analysed using descriptive techniques&#46; Continuous variables were defined using the mean as the measure of central tendency&#44; and the standard deviation as the measure of dispersion&#46; Qualitative variables were expressed as absolute number and percentage&#46; Following this&#44; study groups &#40;PVB and BRILMA&#41; were compared by means of a bivariant analysis&#46; In the case of a continuous contrast variable&#44; the independent samples t test was used&#44; and in the case of a categorical contrast variable&#44; the statistics were calculated by means of the chi-square test&#46; A <span class="elsevierStyleItalic">p</span> value of &#60;0&#46;05 was considered statistically significant&#46; All statistical analysis was performed using PASW<span class="elsevierStyleSup">&#174;</span> v17&#46;0 &#40;SPSS Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0085" class="elsevierStylePara elsevierViewall">A total of 60 female patients were included in the study&#46; All had been scheduled for breast surgery under general anaesthesia&#44; 25 received general anaesthesia combined with PVB&#44; and 35 receive general anaesthesia combined with BRILMA&#46; Patient demographics&#44; physical status&#44; surgical procedure&#44; duration of surgery and length of stay in the PACU are summarised in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; Both groups were homogeneous and comparable in terms of the study variables&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Based on the results of the PQRS&#44; total recovery was achieved in 95&#46;25&#37; of patients in the immediate postoperative period &#40;15<span class="elsevierStyleHsp" style=""></span>min PACU&#41;&#44; in 99&#46;07&#37; at discharge&#44; and in 99&#46;25&#37; at 1 month post surgery&#46; No significant differences were observed between groups in the overall score or the scores recorded for each domain&#46; The scores for each domain are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">In all patients&#44; recovery was sufficient to enable them to be discharged home directly from the PACU&#46; In the nociceptive domain&#44; scores were excellent&#44; despite the fact that opioids were not administered in either group&#46; The percentages of recovery with respect to baseline values in each PQRS domain are shown in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> &#40;entire sample&#41;&#44; and in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> &#40;BRILMA vs PVB&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Overall patient perception was 3&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;30 &#40;4&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;8 in the BRILMA group and 3&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;2 in the PVB group&#41; in the immediate postoperative period &#40;in the PACU&#41;&#44; 3&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;9 &#40;4&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;7 in the BRILMA group and 3&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;8 in the PVB group&#41; at the time of discharge &#40;the day after the intervention&#41;&#44; and 4&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5 &#40;4&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;2 in the BRILMA group and 4&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;6 in the PVB group&#41;&#46; No significant differences were observed between groups &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Six patients presented postoperative nausea and vomiting &#40;4 BRILMA and 2 PVB&#41;&#44; which resolved in all cases with the IV administration of a 4<span class="elsevierStyleHsp" style=""></span>mg bolus of ondansetron&#46; In 5 patients &#40;3 BRILMA and 2 PVB&#41;&#44; postoperative pain was treated in the PACU with morphine &#40;2<span class="elsevierStyleHsp" style=""></span>mg bolus every 5<span class="elsevierStyleHsp" style=""></span>min until an NRS score of less than 3&#44; up to a maximum dose of 0&#46;15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;h&#41;&#46; In all cases&#44; 2 boluses were required&#46; With regard to locoregional anaesthesia-related complications&#44; 1 case of suspected pneumothorax was reported &#40;PVB group&#41;&#46; The patient was admitted and the episode was resolved using a conservation approach&#46; Another patient &#40;BRILMA group&#41; reported distal paresthesia in the right hand&#44; which resolved spontaneously&#46; Length of stay in the PACU did not differ significantly between groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">In each case&#44; the anaesthesiologist rated the difficulty involved in performing the technique as follows&#58; easy&#44; in 35 cases &#40;25 in the BRILMA group and 10 in the PVB group&#41;&#44; rather difficult in 15 cases &#40;10 in the BRILMA group and 5 in the PVB group&#41;&#44; and difficult in 10 cases &#40;all in the BRILMA group&#41;&#46; Patient satisfaction at 24<span class="elsevierStyleHsp" style=""></span>h post surgery was rated as very satisfied in 30 cases &#40;20 in the BRILMA group and 10 in the PVB group&#41;&#44; satisfied in 20 cases &#40;10 in the BRILMA group and 10 in the PVB group&#41;&#44; and neither satisfied nor dissatisfied in 10 cases &#40;5 in the BRILMA group and 5 in the PVB group&#41;&#46; None of the patients rated their experience as unsatisfied&#46; When asked whether they would agree to the same anaesthesia technique if they had to undergo another intervention&#44; all responses were affirmative&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0115" class="elsevierStylePara elsevierViewall">All healthcare professionals involved in the field of surgery share a common goal&#58; to maximise efficacy&#44; safety and efficiency in all procedures in order to achieve the best possible outcome and optimise the patient&#39;s recovery and post surgery quality of life&#46; In such multimodal teams&#44; the anaesthesiologist&#39;s experience and ability to ensure the patient&#39;s well being and safety during the perioperative period are a fundamental part of the process of care&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">17&#8211;19</span></a> This is even more important in cancer surgery&#44; in which the impact of anaesthetics and analgesics on the immunological and inflammatory systems and on angiogenesis has been well documented&#46; However&#44; due to the heterogeneity of studies on the impact of anaesthesia on cancer recurrence&#44; no particular anaesthesia technique has been shown to be superior to any other&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Most quality indicators for surgical outcomes consider factors such as the rate of admission&#44; re-admission and cancellations&#44; serious complications&#44; postoperative nausea and vomiting&#44; postoperative pain&#44; and time to discharge home or transfer to the ward&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> Nevertheless&#44; the quality of our work and its effect on the patient&#39;s life is best judged in scientific and technical terms by the complete recovery of our patients&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> In this study&#44; we used the PQRS questionnaire&#8211;a validated&#44; sensitive and practical clinical research and management instrument&#8211;to measure quality of recovery at various different levels&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> After comparing the means of the overall and domain-specific scores obtained from the PQRS&#44; we obtained a far higher score than that reported for general anaesthesia&#46; Our results confirm the quality of postoperative recovery after a multimodal anaesthesia strategy combining general anaesthesia with ultrasound-guided regional techniques &#40;PVB or BRILMA&#41;&#46; With this approach&#44; full recovery in the immediate postoperative period was achieved in over 95&#37; of cases&#46; However&#44; our results must be viewed in the context of our limited sample size&#44; and the fact that the aim of the study was not to compare the multimodal approach against general anaesthesia&#44; but rather to evaluate perioperative recovery following 2 ultrasound-guided combined anaesthesia techniques&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Most anaesthesiologists are primarily concerned with the physiological safety of their patients&#44; and in most protocols this will determine when the patient is discharged home&#46; However&#44; our anaesthesia and analgesia strategy also determines other medium and long-term outcomes&#46; Two clear examples of this are chronic acute postoperative pain<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">22&#8211;26</span></a> and the relationship between anaesthesia and tumour recurrence&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Chronic pain after breast surgery&#44; which occurs in between 17&#37; and 57&#37; of cases&#44;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> is thought to be caused by several different factors&#44; including age &#8211; it is more prevalent among young patients&#8211;anxiety and depression&#46; However&#44; the main causative factors are the type of surgery and the onset of acute postoperative pain&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">23&#8211;25</span></a> Multimodal analgesic techniques block central sensitisation secondary to the incision and resulting inflammation&#44; thus providing effective pain management and preventing chronicity&#46; Given the multitude of factors involved in chronic pain&#44; however&#44; it is important to approach this phenomenon from a comprehensive&#44; perioperative perspective&#44; instead of focussing on mere pain management&#46; This means providing patient education and information&#44; helping them control their anxiety&#44; tailoring the multimodal anaesthesia&#8211;analgesia technique to the needs of each patient and the requirements of each procedure&#44; and providing good postoperative follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">On this basis&#44; paravertebral or fascial blockade achieves excellent analgesia with minimal opioid administration in the perioperative&#44; early and late postoperative period&#46; This should improve scores in the nociceptive domain&#44; which in turn hastens complete short-term recovery&#46; Nevertheless&#44; in our patients rapid recovery was not limited to pain&#44; but was also observed in other short- and long-term domains&#46; In other words&#44; we achieved faster recovery rates than those reported by other authors using the same scale&#46; In Royse et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> recovery rates improved over time&#44; with physiological recovery being achieved within 40<span class="elsevierStyleHsp" style=""></span>min en in 34&#37; of cases&#46; By the third postoperative day&#44; comprehensive recovery &#40;in all study domains&#41; was only achieved in 11&#37; of cases&#58; 48&#46;7&#37; in the nociceptive domain&#44; 81&#46;3&#37; in the emotional domain&#44; 68&#46;8&#37; in the performance of activities of daily living&#44; and only 33&#46;5&#37; in the cognitive domain&#46; Despite these low recovery scores&#44; 95&#46;8&#37; of patients were either satisfied or very satisfied with the anaesthesia technique used&#46; In our study&#44; recovery occurred earlier&#59; we believe this was because our patients were not premedicated with benzodiazepines&#44; and did not require intraoperative hypnotics or opiates due to the combined regional anaesthesia strategy&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">After analysing our results&#44; we can conclude that&#44; as pain is a complex symptom that is influenced by psychological&#44; cognitive&#44; emotional and sociocultural factors&#44; effective pain management will have a positive effect not only on nociceptive recovery but also on the other domains studied&#46; This effect is not limited to the immediate postoperative period&#44; but continues over long-term follow-up&#44; as shown by the results obtained at 1 month post surgery&#46; This accelerated postoperative recovery is even more important in cancer surgery&#44; as it will enable patients to start radiotherapy or chemotherapy at an earlier stage&#44; and thus improve their long-term prognosis&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Locoregional analgesia techniques&#44; either thoracic paravertebral block &#40;considered the gold standard regional technique for breast surgery&#41; or interfascial blocks&#44; control pain and minimise the need for opioids&#46; This is turn reduces the risk of the appearance of secondary effects both during and immediately after surgery&#46; Although we&#44; the authors&#44; have considerable experience in interfascial blocks&#44;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8&#44;28</span></a> the technique is still in its infancy&#44; and we acknowledge that well-designed multicentre clinical trials are needed to evaluate their advantages over PVBs&#46; However&#44; studies showing their usefulness as an analgesic technique in breast surgery should not be overlooked&#44;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">29&#44;30</span></a> and the results of this study have shown interfascial techniques to be on a par with paravertebral blockade from the perspective of complete patient recovery&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Our study has the following limitations&#58; First&#44; it was carried out at a single site&#44; by a single research team&#46; The anaesthesiologist performing the blockade was familiar with both paravertebral and interfascial block techniques&#44; and with the use of ultrasound to guide target location&#46; Despite this&#44; the serratus-intercostal block used in this study was only introduced recently&#44; and the concentration and volume of local anaesthetic administered are those recommended by Di&#233;guez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a>&#59; we cannot be sure whether a different concentration or volume would have affected our results&#46; Another drawback involves the limitation inherent to the assessment scales used in our study&#44; in the sense that repeat administration of the same questionnaire could cause a &#8220;learning&#8221; bias that would affect our results&#46; However&#44; this same bias would be present in other studies using the PQRS&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In conclusion&#44; both PVB and BRILMA&#44; in the multimodal context of this study&#44; achieve excellent analgesia that considerably reduces the need for opiates&#44; and the scores obtained from the PQRS are far higher than those reported in the context of general anaesthesia&#46; The good results obtained in the nociceptive domain lead in turn to higher scores in the physiological&#44; emotional&#44; functional&#44; cognitive&#44; and overall patient perspective domains&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interest</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare they have no conflict of interest&#46;</p></span></span>"
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              "identificador" => "abst0015"
              "titulo" => "Results"
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              "titulo" => "Conclusions"
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        1 => array:2 [
          "identificador" => "xpalclavsec764110"
          "titulo" => "Keywords"
        ]
        2 => array:3 [
          "identificador" => "xres762597"
          "titulo" => "Resumen"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "abst0025"
              "titulo" => "Introducci&#243;n"
            ]
            1 => array:2 [
              "identificador" => "abst0030"
              "titulo" => "Material y m&#233;todos"
            ]
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              "identificador" => "abst0035"
              "titulo" => "Resultados"
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              "identificador" => "abst0040"
              "titulo" => "Conclusiones"
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          "titulo" => "Palabras clave"
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          "titulo" => "Introduction"
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          "titulo" => "Materials and methods"
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          "titulo" => "Discussion"
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          "identificador" => "sec0025"
          "titulo" => "Conflict of interest"
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          "titulo" => "References"
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    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2015-12-09"
    "fechaAceptado" => "2016-03-12"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec764110"
          "palabras" => array:5 [
            0 => "Breast cancer surgery"
            1 => "General anaesthesia"
            2 => "Total quality management"
            3 => "Postoperative recovery"
            4 => "Regional anaesthesia"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec764111"
          "palabras" => array:5 [
            0 => "Cirug&#237;a de c&#225;ncer de mama"
            1 => "Anestesia general"
            2 => "Gesti&#243;n de calidad total"
            3 => "Recuperaci&#243;n postanest&#233;sica"
            4 => "Anestesia regional"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The quality of postoperative recovery is one of the most important among all the quality indicators used in clinical situations&#46; This is even more important after cancer surgery&#46; Our aim was to evaluate this after non-reconstructive breast surgery under general anaesthesia and paravertebral blockade or serratus&#8211;intercostal plane blockade&#44; in the early and late post-operative period&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A prospective observational study was conducted on 60 patients &#40;25 paravertebral blockade group and 35 serratus&#8211;intercostal plane blockade group&#41; scheduled for non-reconstructive breast surgery during a 6 month period&#46; Every patient received general anaesthesia and were randomised to receive either paravertebral blockade or serratus&#8211;intercostal plane blockade&#46; The quality of post-anaesthetic recovery was quantified by Postoperative Quality Recovery Scale&#44; which is used to assess physiological&#44; nociceptive&#44; emotional&#44; autonomy&#44; cognitive and general state domains at different times&#58; baseline &#40;before surgery&#41;&#44; 15<span class="elsevierStyleHsp" style=""></span>min after the end of surgery&#44; at discharge to home&#44; and one month after surgery&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total recovery of 95&#46;93&#37; was achieved in the early postoperative period &#40;15<span class="elsevierStyleHsp" style=""></span>min PACU&#41;&#44; 99&#46;07&#37; at discharge to home&#44; and 99&#46;25&#37; at one month after the intervention&#46; No significant differences were found between groups in total score or in each evaluated area&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A progressive improvement was observed in the scores assessed with the Postoperative Quality Recovery Scale&#44; reaching values that would allow the discharge to home and early return to usual active life from the immediate postoperative period&#44; with no significant differences between the 2 analgesic techniques&#46; Savings in opioid use and the excellent recovery were observed in all measured domains observed&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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            "titulo" => "Conclusions"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La cuantificaci&#243;n de la calidad de la recuperaci&#243;n posquir&#250;rgica destaca entre los indicadores de calidad utilizados en cl&#237;nica&#46; Ello es m&#225;s importante a&#250;n tras cirug&#237;a oncol&#243;gica&#46; Nuestro objetivo fue evaluar la calidad de la recuperaci&#243;n tras cirug&#237;a no reconstructiva de mama tras anestesia general combinada con bloqueo paravertebral versus bloqueo del espacio serrato-intercostal en el postoperatorio inmediato y tard&#237;o&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional prospectivo en 60 pacientes programadas para cirug&#237;a no reconstructiva de mama en un periodo de 6 meses bajo anestesia combinada general y bloqueo paravertebral &#40;25 pacientes&#41; o bloqueo del espacio serrato-intercostal &#40;35 pacientes&#41;&#46; La calidad de la recuperaci&#243;n postanest&#233;sica se midi&#243; con la escala Postoperative Quality Recovery Scale&#44; valorando los dominios fisiol&#243;gico&#44; nociceptivo&#44; emocional&#44; autonom&#237;a&#44; cognitivo y estado general en diferentes momentos&#58; basal &#40;previo a cirug&#237;a&#41;&#44; 15<span class="elsevierStyleHsp" style=""></span>min tras finalizar la intervenci&#243;n&#44; al alta hospitalaria y al mes postintervenci&#243;n&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se consigui&#243; una recuperaci&#243;n total del 95&#44;93&#37; en el postoperatorio inmediato &#40;15<span class="elsevierStyleHsp" style=""></span>min unidad de recuperaci&#243;n postoperatoria &#91;URPA&#93;&#41;&#44; del 99&#44;07&#37; al alta y del 99&#44;25&#37; al mes de la intervenci&#243;n&#46; No se encontraron diferencias significativas entre ambos grupos ni en la puntuaci&#243;n total ni en las diversas &#225;reas medidas por la escala&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Con la t&#233;cnica descrita se ha objetivado una alta puntuaci&#243;n de recuperaci&#243;n con la Postoperative Quality Recovery Scale&#44; que posibilitar&#237;a el alta en el postoperatorio inmediato y la vuelta precoz a la vida activa habitual&#46; En ambos grupos se observ&#243; un ahorro de opioides y una recuperaci&#243;n excelente de todos los dominios evaluados&#44; sin diferencias significativas&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
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    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Please cite this article as&#58; P&#233;rez Herrero MA&#44; L&#243;pez &#193;lvarez S&#44; Fadrique Fuentes A&#44; Manzano Lorefice F&#44; Bartolom&#233; Bartolom&#233; C&#44; Gonz&#225;lez de Z&#225;rate J&#46; Calidad de la recuperaci&#243;n posquir&#250;rgica tras cirug&#237;a de mama&#46; Anestesia general combinada con bloqueo paravertebral versus bloqueo del espacio serrato-intercostal&#46; Rev Esp Anestesiol Reanim&#46; 2016&#59;63&#58;564&#8211;571&#46;</p>"
      ]
    ]
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Ultrasound-guided thoracic paravertebral approach&#46; Image obtained with the transducer positioned as described in the text&#46; The arrow shows the target local anaesthetic injection site&#44; behind which the corresponding pleural &#8220;ballooning&#8221; should be observed&#46; IICM&#58; Internal intercostal membrane&#59; PL&#58; pleura&#59; PVS&#58; paravertebral space&#59; TP&#58; transverse process&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">BRILMA or serratus&#8211;intercostal block&#46; Image obtained with the transducer positioned on the midaxillary line&#44; as described in the text&#46; The left side of the image faces cranial and the right faces caudal&#46; The arrows show the position of the needle&#46; AL&#58; local anaesthetic&#59; MIc&#58; intercostal muscles&#59; M Serr&#58; serratus muscle&#59; pl&#58; pleura&#59; 4c&#58; fourth rib&#59; 5c&#58; fifth rib&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Domain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Parameters measured&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Observations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Physiologic</span><br>Score range&#58; 9&#8211;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arterial pressure&#44; heart and breathing rate&#44; temperature&#44; and SpO<span class="elsevierStyleInf">2</span>&#46; Airway management&#44; level of agitation&#44; level of consciousness and activity on command relate to airway safety and emergence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The domain is tested in the immediate postoperative period to assess &#8220;home readiness&#8221; for day stay surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Nociceptive</span><br>Score range&#58; 2&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patient&#39;s subjective perception of pain and nausea at the time of testing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Likert face scale &#40;1&#8211;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Emotional</span><br>Score range&#58; 2&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Feelings of anxiety and depression at the time of testing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Likert face scale &#40;1&#8211;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Activities of daily living</span><br>Score range&#58; 4&#8211;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recovery of activities of daily living Ability to stand&#44; walk and dress without assistance&#44; and ability to eat and drink&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Scale&#58; 3<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>easily&#44; 2<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>with difficulty and 1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>not at all&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Cognitive</span><br>Score range&#58; 0&#8211;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Five test assess orientation&#44; verbal memory&#44; executive functioning&#44; attention and concentration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Derived from extensively used neurocognitive tests with their respective scales&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Overall patient perspective</span><br>Score range&#58; 4&#8211;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patients rate their recovery with respect to their activities of daily living&#44; clarity of thought&#44; ability to work and satisfaction with anaesthetic care&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Five-point scale&#46; Return to work is only applied to those who currently work and intend to return after surgery<br>Not included in the analysis as it does not measure recovery with respect to baseline&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Postoperative Quality Recovery Scale domains&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">The PVB group received paravertebral block&#46; No significant differences were observed between groups &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PVB &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">BRILMA &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>35&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6 &#40;31&#8211;87&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10 &#40;29&#8211;65&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weight &#40;kg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9 &#40;45&#8211;98&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18 &#40;47&#8211;90&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Height &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;57<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5 &#40;1&#46;45&#8211;1&#46;82&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6 &#40;1&#46;54&#8211;1&#46;85&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ASA status&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">I &#40;60&#37;&#41;&#44; II &#40;40&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">I &#40;55&#37;&#41;&#44; II &#40;35&#37;&#41;&#44; III &#40;10&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tumorectomy<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>sentinel lymph node &#40;15&#41;<br>Tumorectomy<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>lymphadenectomy &#40;6&#41;<br>Mastectomy<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>lymphadenectomy &#40;4&#41;<br>Lymphadenectomy &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tumorectomy<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>sentinel lymph node &#40;21&#41;<br>Tumorectomy<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>lymph node &#40;6&#41;<br>Mastectomy<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>lymph node &#40;5&#41;<br>Lymphadenectomy &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Location&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Left &#40;15&#41;&#44; right &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Left &#40;22&#41;&#44; right &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duration of surgery &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>32&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">40<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>34&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stay in PACU &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55&#46;34<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Patient demographics&#44; physical status&#44; procedures and times&#46;</p>"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">The table shows the means and standard deviations of the absolute numerical scores obtained in the physiologic&#44; nociceptive&#44; emotional&#44; functional and cognitive domains of all study patients &#40;first row in each subgroup&#58; total&#41;&#44; in the BRILMA group &#40;second row&#41; and the PVB group &#40;third row&#41;&#59; at different study time points&#58; baseline or preoperative&#44; in the PACU&#44; at discharge&#44; and at 1 month&#46; No significant differences were observed between groups &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Physiologic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Nociceptive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Emotional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Functional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cognitive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Baseline</td><td class="td" title="table-entry  " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;27<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;12<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;08<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;91<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BRILMA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;35<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;21<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;42<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;38<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;56<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PVB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;16<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;00<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;64<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;64<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&#46;04<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">PACU</td><td class="td" title="table-entry  " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;29<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;83<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;59<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;95<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&#46;39<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BRILMA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;44<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;66<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;03<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;31<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;17<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PVB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;08<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;08<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;96<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;87<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&#46;67<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">At discharge</td><td class="td" title="table-entry  " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;07<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;90<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;76<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&#46;59<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BRILMA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;35<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;03<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;21<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;26<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PVB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;14<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;96<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;72<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;52<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&#46;48<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">At 1 month</td><td class="td" title="table-entry  " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;22<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;10<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;93<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;91<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&#46;76<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BRILMA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;26<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;20<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;23<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;41<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;46<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PVB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;16<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;96<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;52<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&#46;88<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PACU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">At discharge&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">At 1 month&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Physiologic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#46;08<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&#46;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&#46;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nociceptive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&#46;72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Emotional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">93&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">97&#46;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">97&#46;88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Functional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#46;4<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&#46;49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">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="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cognitive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&#46;72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              "identificador" => "tblfn0005"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Values shown indicate percentage of recovery with respect to the means of the absolute numerical scores obtained with respect to baseline&#46; Note the better scores with respect to baseline obtained in the PACU in the physiologic and functional domains&#46; This is no doubt due to pre-operative anxiety &#40;baseline time point&#41; and the limitations of the PQRS&#46;</p> <p class="elsevierStyleNotepara" id="npar0010">No significant differences were observed between groups &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46;</p>"
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Percentage of patients showing total recovery according to the Postoperative Quality Recovery Scale&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">PACU</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">At discharge</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">At 1 month</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">BRILMA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PVB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">BRILMA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PVB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">BRILMA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PVB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Physiologic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#46;37<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&#46;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&#46;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">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="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nociceptive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#46;14<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&#46;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&#46;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Emotional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">94&#46;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">89&#46;76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">94&#46;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101&#46;2<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">97&#46;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&#46;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Functional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">102&#46;16<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&#46;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#46;32<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&#46;62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cognitive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&#46;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&#46;91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&#46;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&#46;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">93&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&#46;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&#46;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&#46;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&#46;65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            0 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Values shown indicate percentage of recovery with respect to the means of the absolute numerical scores obtained with respect to baseline&#46; Note the better scores obtained in the PACU in the physiologic and functional domains in the BRILMA group and in the nociceptive and emotional domains in the PVB group&#46; This is no doubt due to both preoperative anxiety &#40;baseline time point&#41;&#44; that affected all study domains&#44; and the heterogeneity of the sample&#46;</p> <p class="elsevierStyleNotepara" id="npar0020">No significant differences were observed between groups &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46;</p>"
            ]
          ]
        ]
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          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Recovery percentage&#44; BRILMA vs PVB&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:30 [
            0 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "Available from&#58; <a class="elsevierStyleInterRef" id="intr0010" href="http://encr.eu/images/docs/factsheets/breast-factsheets.pdf">http&#58;&#47;&#47;encr&#46;eu&#47;images&#47;docs&#47;factsheets&#47;breast-factsheets&#46;pdf</a> &#91;accessed 02&#46;09&#46;15&#93;"
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46;E&#46; Tyczynski"
                            1 => "F&#46; Bray"
                            2 => "D&#46;M&#46; Parkin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:2 [
                        "fecha" => "December 2002"
                        "editorial" => "International Agency for Research on Cancer&#46; ENCR Cancer Fact Sheets"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Paravertebral blocks in breast cancer surgery&#58; is there a difference in postoperative pain&#44; nausea&#44; and vomiting&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "R&#46; Aufforth"
                            1 => "J&#46; Jain"
                            2 => "J&#46; Morreale"
                            3 => "R&#46; Baumgarten"
                            4 => "J&#46; Falk"
                            5 => "C&#46; Wesen"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1245/s10434-011-1899-5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Surg Oncol"
                        "fecha" => "2012"
                        "volumen" => "19"
                        "paginaInicial" => "548"
                        "paginaFinal" => "552"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21769470"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
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Article information
ISSN: 23411929
Original language: English
DOI:10.1016/j.redare.2016.07.002
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