Physical activity and frailty as indicators of cardiorespiratory reserve and predictors of surgical prognosis: General and digestive surgery population characterization | Revista Española de Anestesiología y Reanimación (English Edition)

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Dana, D. Capitán, M. Ubré, A. Hervás, R. Risco, G. Martínez-Pallí" "autores" => array:6 [ 0 => array:4 [ "nombre" => "F." "apellidos" => "Dana" "email" => array:1 [ 0 => "fjdana@clinic.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "D." "apellidos" => "Capitán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Ubré" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "A." "apellidos" => "Hervás" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "R." "apellidos" => "Risco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "G." "apellidos" => "Martínez-Pallí" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Área Quirúrgica, Hospital Clínic de Barcelona, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Clínic de Barcelona, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Institut Clínic de Malalties Digestives, Hospital Clínic de Barcelona, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Actividad física y fragilidad como indicadores de reserva cardiorrespiratoria y predictores del pronóstico quirúrgico: caracterización de la población quirúrgica en cirugía general y digestiva" ] ] "textoCompleto" => "IntroductionSurgery, even in the absence of complications, causes a patient's health to deteriorate to the point where they are either totally or partially incapacitated for a certain length of time.<a class="elsevierStyleCrossRef" href="#bib0150">1</a> The duration of this period of disability and the care needed depend as much on the extent of the surgery and the appearance of peri- and postsurgical complications as on the preoperative status of the individual.Medicine has progressed in recent years to the point the surgical morbidity is now greatly improved, making surgery a safer process that can be performed on a larger range of patients. As a result, it is increasingly common for both complex and elderly patients to undergo aggressive surgical procedures, and the pre-surgical work-up must now focus on evaluating not only the patient's chances of being cured, but also their chances of surviving the surgery with an acceptable quality of life. Risk stratification has proved to be a fundamental tool for allowing clinicians, health authorities, hospital managers and patients to make decisions that will contribute to improve quality of care and efficiency.A low level of physical activity and a low functional reserve, quantified using various tests, such as the 6-min walk test or more complex tests such as the cardiopulmonary exercise test, are predictive factors for postoperative complications, disability, institutionalisation, and even postoperative mortality.<a class="elsevierStyleCrossRefs" href="#bib0155">2,3</a> Frailty, defined as a condition associated with low physiological functional reserve and greater vulnerability to stress situations, has also been shown to be a predictor of poor postoperative prognosis.<a class="elsevierStyleCrossRefs" href="#bib0165">4,5</a>In this context, several interventions aimed at improving all these factors have been proposed in an attempt to improve postoperative outcomes. For example, pre-habilitation, defined as the process of enhancing a patient's functional capacity before scheduled surgery, has emerged as a highly promising strategy.<a class="elsevierStyleCrossRef" href="#bib0175">6</a> A key element in improving surgical outcomes is the development of standardised protocols that can identify patients at greater risk, allowing clinicians to individualise the measures taken and implement prehabilitation programmes. First, however, we need to characterise the target population. It should be borne in mind that the unique characteristics of each population are affected by environmental, socio-economic and cultural factors–in other words, individual lifestyles.The aim of the present study was to characterise, from a functional perspective, patients who are candidates for surgery. This characterisation will, we hope, lead to the creation of interventions aimed at pre-habilitating frail patients prior to surgery.MethodsStudy design and subjectsWe conducted a prospective observational study in which all patients scheduled for preoperative evaluation before elective general and gastrointestinal surgery requiring hospital admission were enrolled consecutively between March and May 2015 at the Hospital Clínic de Barcelona. Exclusion criteria were: language barrier, cognitive alterations that would prevent the patient from adequately understanding the tests administered, and functional or motor limitations in the lower extremities that would prevent the patient from performing the functional tests. The study was approved by the Institutional Review Board, and all patients signed an informed consent form before participating in the study.MeasurementsPatients were invited to participate in the study on the same day they visited the hospital for the conventional pre-anaesthetic assessment. If they accepted, they were asked to complete the questionnaires and tests listed below.Level of physical activityThe level of physical activity was quantified by the short version of the International Physical Activity Questionnaire (IPAQ),<a class="elsevierStyleCrossRefs" href="#bib0180">7,8</a> designed to determine activity levels in the adult population. It calculates the volume of physical activity by weighting each type of activity by its energy requirements defined in metabolic equivalents (MET), which are multiples of the resting metabolic rate. The questionnaire establishes the following categories of physical activity: (a) low/inactive, if weekly activity is below 600 METs; (b) moderately intensity activity, between 600 and 3000 METs, and (c) vigorous intensity activity, higher than 3000 METs. The short version of the IPAQ questionnaire also records the number of hours a day that subjects remain seated.Functional capacityFunctional capacity or cardiopulmonary reserve was assessed using the Duke Activity Status Index (DASI)<a class="elsevierStyleCrossRef" href="#bib0190">9</a> and the 5 Times Sit-to-Stand Test, (5XSST).The DASI is a 12-item questionnaire that utilises self-reported physical work capacity, and assesses the functional and aerobic capacity of the individual (maximum oxygen consumption). Previous studies have shown that in all cases a score of over 46 is accompanied by an anaerobic threshold above 11ml/kg/min and, therefore, adequate cardiopulmonary respiratory reserve.<a class="elsevierStyleCrossRef" href="#bib0190">9</a>The 5XSST is a physical test that consists of timing the subject while they stand up and sit down in a chair as fast as possible 5 times, without supporting themselves with their arms. The time taken to repeat the movement 5 time is related to leg strength and, therefore, to functional capacity during the most demanding day-to-day activities, such as: climbing stairs, getting up from a chair, from the bath, or from a horizontal position.<a class="elsevierStyleCrossRefs" href="#bib0195">10,11</a> The 5XSST is also useful for measuring fatigue caused by repeatedly sitting and standing and, therefore, is a surrogate measure of cardiopulmonary reserve. The test was performed using a normal armchair, with a seat at a height of 40cm. The test started with the subject sitting on the chair. At the command of “1, 2, 3, go”, the subject stood up and sat down 5 times as fast as possible, with their arms crossed on their chest. All tests were performed using the same chair, in similar ambient conditions. Subjects were only allowed to use their hands to get up if they were unable to perform a repetition without assistance. This was annotated in the data collection form.FrailtyThe Canadian Study of Health and Ageing (Clinical Frailty Scale)<a class="elsevierStyleCrossRef" href="#bib0205">12</a> was used to measure frailty. This is a fully validated, easily administered scale in which subjects are assigned to one of 9 categories, ranging from 1–very fit, to 9–totally dependent, terminally ill. The scale considers various factors, such as morbidity, cognitive impairment and degree of dependence. Frail patients are all those assigned to categories 4–9.Emotional stateDue to the psychological stress that an impending surgical intervention can cause, we also evaluated each subject's emotional state. For this purpose, we used the 14-item Hospital Anxiety and Depression Scale, (HADS),<a class="elsevierStyleCrossRef" href="#bib0210">13</a> in which 7 items assess anxiety and 7 assess depression. Each item is scored from 0 to 3, so an individual can score between 0 and 21 for either anxiety or depression. The HADS assesses the patient's status in the previous week. In addition to quantitative assessment, patients can be stratified into no anxiety or no depression if HADS scores are below 8; possible or doubtful for scores between 8 and 10, and probable or affirmative if they are 11 or higher. For this study, a cut-off score of 10 was chosen for each scale.<a class="elsevierStyleCrossRef" href="#bib0215">14</a>Other variablesAll the questionnaires were self-administered, although patients were able to ask the interviewer to read and clarify the questions when necessary.Sociodemographic variables (alcohol and/or tobacco consumption, degree of dependency and presence of caregivers), clinical variables (body mass index, presence of comorbidities, American Society of Anesthesiologists [ASA] physical status classification) and surgery-related variables (type of surgery, previous neoadjuvant treatments, expected duration of surgery, etc.) were also collected.Finally, a brief semi-structured interview was conducted to evaluate the patient's willingness to join a physical rehabilitation programme in the future.Statistical analysisDescriptive variables are expressed as mean and standard deviation or frequency, according to the type of variable. Inter-group comparisons were performed using the Chi-square test in the case of qualitative variables and the Student's t-test for quantitative variables. Statistical analysis was performed on SPSS® version 20.0.ResultsCharacteristics of the study populationA total of 140 patients met the inclusion criteria and were invited to participate in the study. Only 8 of the patients scheduled for preoperative evaluation before elective general and gastrointestinal surgery requiring hospital admission were excluded (3 due to language barrier or cognitive impairment, 3 due to refusal to participate in the study, and 2 due to physical incapacity to perform part of the tests). The demographic characteristics of the sample are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Mean age was 60±15 years, 56% were males, and 25% of patients were ASA class III or IV. Most (78%) subjects came from the metropolitan area of Barcelona, while the remaining 22% lived in rural areas. Nearly half (49%) were scheduled for cancer surgery.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Physical activity level (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). The level of physical activity in the previous week, evaluated using the IPAQ questionnaire, showed a very sedentary population, with over two thirds of the patients (70%) scoring 600 METs/week, with a mean of 667±180 METs/week. The average number of sedentary hours per day was 6.3±4h, while 21 individuals (15%) were sedentary for 10h or more per day.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Functional capacity (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Functional reserve, estimated using the DASI questionnaire, was low (score<46) in 68% of study patients.The 5XSST has only been validated in population groups aged 60 years or older. In our population, half the individuals were younger than 60 years, and there are no reference values for subjects of this age. For this reason, we decided to use the reference values established for the 60–69 age group proposed by Bohannon.<a class="elsevierStyleCrossRef" href="#bib0220">15</a> Over half (53%) of patients aged under the age of 60 took longer than predicted for their age group to perform the 5XSST, showing diminished lower limb muscle strength (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). This proportion was even higher in the older age groups.Frailty.<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the distribution of patients according to the Canadian Study of Health and Ageing scale. Very few (18%) study patients were classified as frail under this scale.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Emotional state. The prospect of surgery elicited a clear anxiety-depressive syndrome in only 8% of patients (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).Determinants of low functional reserveBased on previous studies showing that a DASI score of over 46 is associated with an anaerobic threshold above 11ml/kg/min, the 140 study patients were divided into 2 groups according their DASI score: low functional reserve (DASI<46, n=94) and normal functional reserve (DASI≥46, n=46) (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>). Patients with low functional reserve were older (66±11 vs 48±14 years, p<0.05) and presented more comorbidities. This group also included a higher percentage of ASA class III and IV (34% vs 7%, p<0.05) than patients with normal functional reserve. There were no significant differences with regard to sex, body mass index or place of residence (urban or rural). The low functional reserve group included a higher percentage of patients scheduled for cancer surgery (55% vs 32%), although there were no differences in the percentage of patients who had previously received adjuvant chemotherapy and/or radiotherapy. Similarly, the percentage of sedentary patient was significantly higher in the low functional reserve group (75% vs 56%, p<0.05). While no patients in the normal functional reserve group had a total HADS score of over 20, 13% of patients with low functional reserve had a clear anxiety-depressive syndrome. In addition, mean scores for each scale were higher in this group.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>After the evaluation, patients were asked to complete a short survey consisting of multiple-choice questions. The results are shown in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>. Nearly all (90%) patients felt that a preoperative training programme might help improve their fitness for surgery.<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>DiscussionThis study characterises, from a functional perspective, the surgical population in our setting, namely the main tertiary level public hospital in an area of the city of Barcelona serving a population of 540,000. Our results highlight the low preoperative cardiopulmonary reserve in this population, associated with a high proportion of frail patients and patients with a sedentary lifestyle. Over two thirds of patients scheduled for general and gastrointestinal surgery presented low functional or cardiopulmonary reserve and had a sedentary lifestyle. In view of the recently confirmed association between these factors and increased surgical morbidity and mortality,<a class="elsevierStyleCrossRefs" href="#bib0155">2,3</a> our findings are alarming, and show the urgent need for corrective measures to improve surgical outcomes.Despite advances in medicine, postoperative complications continue to have a significant impact on clinical outcomes, quality of life, short- and medium-term survival, and healthcare costs. The importance of the problem is due, in large part, to the increase in surgical indications in high-risk population groups, particularly elderly patients with important comorbidities. As a recent multicentre European study has shown, the postoperative mortality rate is currently 4%, although rates for individual countries vary greatly (from 1.2% to 21.5%).<a class="elsevierStyleCrossRef" href="#bib0225">16</a> Even in procedures with a good outcome, postoperative complications continue to be a major problem. Therefore, preoperative identification of high surgical risk patients enables clinicians to establish strategies for the prevention, detection and early treatment of potential complications in order to reduce their incidence and severity, and thus minimise their impact.The extent of the surgery and the presence of cardiopulmonary comorbidities determine the onset of postoperative complications and the risk of death.<a class="elsevierStyleCrossRef" href="#bib0230">17</a> Various studies have shown that patients with low cardiopulmonary reserve are unable to respond to the increased metabolic demand arising from surgery, and are more susceptible to complications.<a class="elsevierStyleCrossRef" href="#bib0235">18</a> In fact, low preoperative exercise tolerance has been associated with a higher incidence of surgery-related complications and mortality.<a class="elsevierStyleCrossRef" href="#bib0240">19</a> Cardiopulmonary exercise testing is considered the gold standard for measuring an individual's aerobic capacity; however, these tests, which are complex and costly, are not routinely performed. Fortunately, several questionnaires and simple tests, such as those used in our study, are now available. Despite their limitations, these are extremely useful routine screening tools. In our experience, they can be completed in 15min, and can be administered by the nurses in the anaesthesiology department. For example, the DASI questionnaire, recommended by the American Heart Association for preoperative assessment of functional status, has shown good correlation with peak oxygen consumption (a parameter derived from the cardiopulmonary exercise test) in surgical patients.<a class="elsevierStyleCrossRef" href="#bib0185">8</a> Specifically, Struthers et al.<a class="elsevierStyleCrossRef" href="#bib0190">9</a> showed that 100% of patients with DASI>46 were able to walk more than 360m in the 6-min walk test (a submaximal exercise test) and had a peak oxygen consumption of over 15ml O2/kg/min, and were therefore considered low risk for postoperative complications.Furthermore, a recent study<a class="elsevierStyleCrossRef" href="#bib0245">20</a> in patients undergoing major oncological abdominal surgery showed that adequate activity level was the only independent factor associated with lower postoperative morbidity and mortality, and is an even better predictor than age and comorbidities such as heart disease. These data are consistent with studies evaluating physical activity, aerobic capacity and speed of postoperative recovery after major surgery.<a class="elsevierStyleCrossRefs" href="#bib0155">2,3</a> The percentage of sedentarism observed in the study population is strikingly higher than previous published data for Spain. In this regard, it is important to emphasise that our patients were awaiting surgery, so the very condition that indicated the need for surgery could have affected their general status and their lifestyle.Frailty is a multidimensional syndrome characterised by a decline in the physiological reserve of organs and systems that places the individual at increased risk of disability and makes them vulnerable to external stresses,<a class="elsevierStyleCrossRef" href="#bib0250">21</a> such as surgery. Frailty has recently been shown to be a determining factor in the appearance postoperative complications, exacerbation or worsening of underlying diseases, longer hospital stay, institutionalisation and death.<a class="elsevierStyleCrossRefs" href="#bib0255">22,23</a> Advanced age and frailty are entirely different concepts and should not be confused, even though the incidence of frailty obviously increases with age<a class="elsevierStyleCrossRef" href="#bib0265">24</a> (it is estimated to occur in around 7% of individuals over the age of 65),<a class="elsevierStyleCrossRef" href="#bib0270">25</a> and the appearance of concomitant diseases, more frequent in elderly individuals, will accelerate the process. Previous studies have shown that over 50% of patients over 65 present concomitant diseases.<a class="elsevierStyleCrossRef" href="#bib0275">26</a> In fact, the average age of our patients was 60 years (half were less than 60), and almost 1 in 5 met the criteria for frailty. In addition, the percentage of ASA III – IV patients was 4 times higher in the frail group, and the incidence of sedentary lifestyle increased from 57% in non-frail patients to 92% in frail patients, in other words, almost all frail patients were sedentary. An increase in life expectancy in developed countries will probably bring with it an increase in the number of frail individuals undergoing surgery. However, frailty can be reversed to a certain extent, and studies have shown it can even be prevented through programmes that increase physical activity in the older population.<a class="elsevierStyleCrossRef" href="#bib0280">27</a> Although surgery is generally perceived as a major stressor, the HADS questionnaire showed that few of our subjects presented preoperative anxiety or depression. This could indicate that the questionnaire, which is designed for hospitalised patients, is not the most appropriate tool for measuring pre-surgical stress. The association between low functional reserve and anxiety and depression, however, is striking.Based on the hypothesis that increased physical activity and training can improve the sedentarism, frailty and low functional reserve that characterises this population, pre-habilitation is a highly promising preventive intervention that can not only prove clinically effective, but also reduce healthcare costs. Pre-habilitation consists of a physical training programme combined with improvements in lifestyle that is followed by surgical patients in the preoperative period to improve their aerobic capacity.<a class="elsevierStyleCrossRefs" href="#bib0285">28,29</a> The aim is to increase the patient's functional capacity to overcome the consequences of surgical stress, thus reducing the incidence and severity of postoperative complications. Interestingly, our survey shows that 90% of patients admit that a training programme could improve their pre-surgical physical condition, and expressed their willingness to receive help in this regard. Participating in such a programme could have a beneficial effect not only in the short term (surgical outcomes), but also in the long term (change in lifestyle).Obviously, our small sample size limits the strength of the conclusions drawn in this study; nevertheless, our randomly selected population reveals a real problem of our society: the high rate of sedentarism and frailty. Enlarging the sample to include patients scheduled for different surgeries would give clearer insight into the determining factors and potential strategies.In conclusion, the present study shows that the population of a tertiary hospital in a city like Barcelona is characterised by a high (>60%) prevalence of low cardiopulmonary reserve and sedentarism. Both these factors are associated with a poor surgical prognosis. The systematic use of simple tests and questionnaires to identify risk groups and plan the appropriate preoperative treatment and implement pre-habilitation programmes should form part of routine preoperative care.Ethical disclosuresProtection of human and animal subjectsThe authors declare that the procedures followed were in accordance with the regulations of the responsible Clinical Research Ethics Committee and in accordance with those of the World Medical Association and the Helsinki Declaration.Confidentiality of dataThe authors declare that they have adhered to the protocols of their centre of work on patient data publication.Right to privacy and informed consentThe authors must have obtained the informed consent of the patients and/or subjects mentioned in the article. The author for correspondence must be in possession of this document.Conflict of interestThe authors declare they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres978768" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec947854" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres978767" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec947855" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study design and subjects" ] 1 => array:3 [ "identificador" => "sec0020" "titulo" => "Measurements" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Level of physical activity" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Functional capacity" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Frailty" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Emotional state" ] 4 => array:2 [ "identificador" => "sec0045" "titulo" => "Other variables" ] ] ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0055" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Characteristics of the study population" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "Determinants of low functional reserve" ] ] ] 7 => array:2 [ "identificador" => "sec0070" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0080" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0085" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0090" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0095" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflict of interest" ] 10 => array:2 [ "identificador" => "xack332003" "titulo" => "Acknowledgments" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-01-23" "fechaAceptado" => "2017-04-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec947854" "palabras" => array:6 [ 0 => "Physical activity" 1 => "Functional capacity" 2 => "Frailty" 3 => "Surgical outcome" 4 => "Postoperative complications" 5 => "Prehabilitation" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec947855" "palabras" => array:6 [ 0 => "Actividad física" 1 => "Capacidad funcional" 2 => "Fragilidad" 3 => "Pronóstico quirúrgico" 4 => "Complicaciones postoperatorias" 5 => "Prehabilitación" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionFrailty and low physical activity and cardiorespiratory reserve are related to higher perioperative morbimortality. The crucial step in improving the prognosis is to implement specific measures to optimise these aspects. It is critical to know the magnitude of the problem in order to implement preoperative optimisation programmes. ObjectiveTo characterise surgical population in a university hospital. MethodsAll patients undergoing preoperative evaluation for abdominal surgery with admission were prospectively included during a 3-month period. Level of physical activity, functional capacity, frailty and emotional state were assessed using score tests. Additionally, physical condition was evaluated using 5 Times Sit-to-Stand Test. Demographic, clinical and surgical data were collected. ResultsOne hundred and forty patients were included (60±15yr-old, 56% male, 25% ASA III or IV). Forty-nine percent of patients were proposed for oncologic surgery and 13% of which had received neoadjuvant treatment. Seventy percent of patients presented a low functional capacity and were sedentary. Eighteen percent of patients were considered frail and more than 50% completed the 5 Times Sit-to-Stand Test at a higher time than the reference values adjusted to age and sex. Advanced age, ASA III/IV, sedentarism, frailty and a high level of anxiety and depression were related to a lower functional capacity. ConclusionsThe surgical population of our area has a low functional reserve and a high index of sedentary lifestyle and frailty, predictors of postoperative morbidity. It is mandatory to implement preoperative measures to identify population at risk and prehabilitation programmes, considered highly promising preventive interventions towards improving surgical outcome." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónUna baja reserva cardiorrespiratoria, un bajo nivel de actividad física y la fragilidad se relacionan con una mayor morbimortalidad perioperatoria. Implementar medidas para optimizar estos aspectos es clave para mejorar el pronóstico. Es fundamental conocer la magnitud del problema para dimensionar los programas de optimización preoperatoria. ObjetivoCaracterizar la población quirúrgica de un hospital universitario de nivel terciario. MétodosSe incluyeron prospectivamente todos los pacientes sometidos a evaluación preoperatoria para cirugía digestiva con ingreso durante 3 meses. Se evaluó el nivel de actividad física, la capacidad funcional, la fragilidad y el estado emocional, y se realizó un test de medición del estado físico (5 Times Sit-to-Stand Test). Se recogieron datos demográficos, clínicos y relacionados con la cirugía. ResultadosSe incluyeron 140 pacientes (60±15 años, 56% varones, 25% ASA III o IV). El 49% estaban propuestos para cirugía oncológica y un 13% había recibido neoadyuvancia. El 70% de los pacientes presentaban una capacidad funcional reducida y eran sedentarios. Un 18% fueron considerados frágiles y más de un 50% completaron el 5 Times Sit-to-Stand Test en un tiempo superior a los valores de referencia. La edad avanzada, el ASA III/IV, el sedentarismo, la fragilidad y un nivel de ansiedad/depresión elevado se relacionaron con una menor capacidad funcional. ConclusionesLa población quirúrgica de nuestro entorno tiene una baja reserva funcional y un elevado índice de sedentarismo y fragilidad, factores asociados a un peor pronóstico quirúrgico. Urge implementar medidas preoperatorias para identificar la población de riesgo y programas de prehabilitación considerados estrategias de optimización preoperatoria con gran potencial." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Dana F, Capitán D, Ubré M, Hervás A, Risco R, Martínez-Pallí G. Actividad física y fragilidad como indicadores de reserva cardiorrespiratoria y predictores del pronóstico quirúrgico: caracterización de la población quirúrgica en cirugía general y digestiva. Rev Esp Anestesiol Reanim. 2018;65:5–12." ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "ASA: American Society of Anesthesiologists; BMI: body mass index; M: men; SD: standard deviation; W: women." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age in years, mean±SD (range) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60±15 (18–92) \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">Sex (M/W), % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56/44 \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">BMI, mean±SD (range) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28±7 (18–54) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Smoking history, %</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Active smoker \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 \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">Former smoker \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">39 \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">Never smoker \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Clinical characteristics, %</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ASA III-IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Comorbidities</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cardiovascular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50 \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">Respiratory \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \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">Diabetes mellitus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Dependency, %</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Requires full-time care \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \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">Requires part-time care \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Occupation, %</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Active \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28 \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">Sick leave \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 \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">Retired \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">49 \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">Student \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \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">Domestic work \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \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">Unemployed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Type of surgery, %</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oncological \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">49 \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">Previous adjuvant \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Type of surgery</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Colorectal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29 \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">Hepatobiliary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 \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">Gastroesophageal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 \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">Endocrine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 \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">Abdominal wall \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \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">Pancreatic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1658248.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical and demographic characteristics." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "CHSA: Canadian Study of Health and Ageing, Clinical Frailty Scale; DASI: Duke Activity Status Index; HADS: Hospital Anxiety and Depression Scale; IPAQ: International Physical Activity Questionnaire; MET: metabolic equivalent." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Physical Activity (IPAQ), n (%)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sedentary (<600MET/wk) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96 (69) \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">Moderate physical activity (600–3000METs/wk) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42 (30) \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">Intense physical activity (>3000METs/wk) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Functional reserve, n (%)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DASI score<46 (low reserve) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">94 (68) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">5 Times Sit-to-Stand Test, patients above reference value</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><60 years (11.4s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34 (53) \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">60–69 years (11.4s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34 (81) \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">70–79 years (12.6s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (91) \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">80–89 years (14.8s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (60) \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">>89 years (14.8s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (50) \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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95 (67) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Frailty (CHSA), n (%)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients scoring≥4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 (18) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Emotional state (HADS), n (%)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anxiety/depression (HADS > 20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (8.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1658244.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Level of physical activity, functional reserve, frailty and emotional state." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Canadian Study of Health and Ageing, Clinical Frailty Scale</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Score \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">Characteristics \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">n (%) \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">1. Very fit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Active, energetic, no concurrent diseases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (7) \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">2. Well \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No symptomatology, occasionally active \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51 (36) \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">3. Managing well \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Well controlled disease, not regularly active beyond routine walking \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55 (39) \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">4. Vulnerable \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Symptomatic concomitant disease limiting activity, independent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (11) \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">5. Mildly frail \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Needs help with instrumental activities of daily living \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (6) \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">6. Moderately frail \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dependent for all activities outside and inside the home (bathing) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (1) \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">7. Severely frail \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Completely dependent for personal care, not at high risk of dying (6 months) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \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">8. Very Severely Frail \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Completely dependent, approaching the end of life \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \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">9. Terminally Ill \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Life expectancy<6 months, but not otherwise evidently frail \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1658245.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Incidence of frailty according to the Canadian fragility scale." ] ] 3 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "5XSST: 5 Times Sit-to-Stand Test; A&D: anxiety and depression; ASA: American Society of Anesthesiologists; BMI: body mass index; CHSA: Canadian Study of Health and Ageing, Clinical Frailty Scale; DASI: Duke Activity Status Index; HADS: Hospital Anxiety and Depression Scale; M: men; ns: not significant; SD: standard deviation; W: women." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \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">Patients with low functional reserve (DASI<46) (n=94) \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">Patients with adequate functional reserve (DASI>46) (n=46) \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">p \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 in years, mean±SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">66±11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">48±14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.05 \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">Sex, M/W, n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">53/41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25/21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns \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">BMI in kg/m2, mean±SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28±6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28±7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns \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 III-IV, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32 (34) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.05 \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">Oncological surgery, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52 (55) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 (32) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.05 \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">Neoadyuvant therapy, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 (13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 (13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns \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">Sedentary lifestyle, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">69 (73) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27 (58) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.05 \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">5XSST above average, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">74 (79) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 (46) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.05 \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">Frail CHSA≥4, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 (27) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.05 \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">HADS (A&D)>20, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 (13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.05 \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">Anxiety scale score>10, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19 (20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.05 \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">Depression scale score>10, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 (7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1658247.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Patient characteristics according to functional reserve." ] ] 4 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Questions \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">Yes, % \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">Do you think that improving your fitness through an exercise programme would be useful to prepare for your surgery? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">91 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">If yes, select the option that best describes how you would prefer to follow such a programme</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">On your own \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \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">Outside the hospital, following instructions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45 \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">In the hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1658246.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Survey on joining a pre-habilitation programme." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:29 [ 0 => array:3 [ "identificador" => "bib0150" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Postoperative fatigue" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T. 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Physical activity and frailty as indicators of cardiorespiratory reserve and predictors of surgical prognosis: General and digestive surgery population characterization

Actividad física y fragilidad como indicadores de reserva cardiorrespiratoria y predictores del pronóstico quirúrgico: caracterización de la población quirúrgica en cirugía general y digestiva

F. Danaa,

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fjdana@clinic.cat

Corresponding author.

, D. Capitána, M. Ubréb, A. Hervásc, R. Riscob, G. Martínez-Pallíb,d

a Área Quirúrgica, Hospital Clínic de Barcelona, Barcelona, Spain

b Servicio de Anestesiología y Reanimación, Hospital Clínic de Barcelona, Barcelona, Spain

c Institut Clínic de Malalties Digestives, Hospital Clínic de Barcelona, Barcelona, Spain

d Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Surgery&#44; even in the absence of complications&#44; causes a patient&#39;s health to deteriorate to the point where they are either totally or partially incapacitated for a certain length of time&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">1</span></a> The duration of this period of disability and the care needed depend as much on the extent of the surgery and the appearance of peri- and postsurgical complications as on the preoperative status of the individual&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Medicine has progressed in recent years to the point the surgical morbidity is now greatly improved&#44; making surgery a safer process that can be performed on a larger range of patients&#46; As a result&#44; it is increasingly common for both complex and elderly patients to undergo aggressive surgical procedures&#44; and the pre-surgical work-up must now focus on evaluating not only the patient&#39;s chances of being cured&#44; but also their chances of surviving the surgery with an acceptable quality of life&#46; Risk stratification has proved to be a fundamental tool for allowing clinicians&#44; health authorities&#44; hospital managers and patients to make decisions that will contribute to improve quality of care and efficiency&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A low level of physical activity and a low functional reserve&#44; quantified using various tests&#44; such as the 6-min walk test or more complex tests such as the cardiopulmonary exercise test&#44; are predictive factors for postoperative complications&#44; disability&#44; institutionalisation&#44; and even postoperative mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">2&#44;3</span></a> Frailty&#44; defined as a condition associated with low physiological functional reserve and greater vulnerability to stress situations&#44; has also been shown to be a predictor of poor postoperative prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In this context&#44; several interventions aimed at improving all these factors have been proposed in an attempt to improve postoperative outcomes&#46; For example&#44; pre-habilitation&#44; defined as the process of enhancing a patient&#39;s functional capacity before scheduled surgery&#44; has emerged as a highly promising strategy&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">6</span></a> A key element in improving surgical outcomes is the development of standardised protocols that can identify patients at greater risk&#44; allowing clinicians to individualise the measures taken and implement prehabilitation programmes&#46; First&#44; however&#44; we need to characterise the target population&#46; It should be borne in mind that the unique characteristics of each population are affected by environmental&#44; socio-economic and cultural factors&#8211;in other words&#44; individual lifestyles&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of the present study was to characterise&#44; from a functional perspective&#44; patients who are candidates for surgery&#46; This characterisation will&#44; we hope&#44; lead to the creation of interventions aimed at pre-habilitating frail patients prior to surgery&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Study design and subjects</span><p id="par0030" class="elsevierStylePara elsevierViewall">We conducted a prospective observational study in which all patients scheduled for preoperative evaluation before elective general and gastrointestinal surgery requiring hospital admission were enrolled consecutively between March and May 2015 at the Hospital Cl&#237;nic de Barcelona&#46; Exclusion criteria were&#58; language barrier&#44; cognitive alterations that would prevent the patient from adequately understanding the tests administered&#44; and functional or motor limitations in the lower extremities that would prevent the patient from performing the functional tests&#46; The study was approved by the Institutional Review Board&#44; and all patients signed an informed consent form before participating in the study&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Measurements</span><p id="par0035" class="elsevierStylePara elsevierViewall">Patients were invited to participate in the study on the same day they visited the hospital for the conventional pre-anaesthetic assessment&#46; If they accepted&#44; they were asked to complete the questionnaires and tests listed below&#46;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Level of physical activity</span><p id="par0040" class="elsevierStylePara elsevierViewall">The level of physical activity was quantified by the short version of the International Physical Activity Questionnaire &#40;IPAQ&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#44;8</span></a> designed to determine activity levels in the adult population&#46; It calculates the volume of physical activity by weighting each type of activity by its energy requirements defined in metabolic equivalents &#40;MET&#41;&#44; which are multiples of the resting metabolic rate&#46; The questionnaire establishes the following categories of physical activity&#58; &#40;a&#41; low&#47;inactive&#44; if weekly activity is below 600 METs&#59; &#40;b&#41; moderately intensity activity&#44; between 600 and 3000 METs&#44; and &#40;c&#41; vigorous intensity activity&#44; higher than 3000 METs&#46; The short version of the IPAQ questionnaire also records the number of hours a day that subjects remain seated&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Functional capacity</span><p id="par0045" class="elsevierStylePara elsevierViewall">Functional capacity or cardiopulmonary reserve was assessed using the Duke Activity Status Index &#40;DASI&#41;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a> and the 5 Times Sit-to-Stand Test&#44; &#40;5XSST&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The DASI is a 12-item questionnaire that utilises self-reported physical work capacity&#44; and assesses the functional and aerobic capacity of the individual &#40;maximum oxygen consumption&#41;&#46; Previous studies have shown that in all cases a score of over 46 is accompanied by an anaerobic threshold above 11<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;min and&#44; therefore&#44; adequate cardiopulmonary respiratory reserve&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The 5XSST is a physical test that consists of timing the subject while they stand up and sit down in a chair as fast as possible 5 times&#44; without supporting themselves with their arms&#46; The time taken to repeat the movement 5 time is related to leg strength and&#44; therefore&#44; to functional capacity during the most demanding day-to-day activities&#44; such as&#58; climbing stairs&#44; getting up from a chair&#44; from the bath&#44; or from a horizontal position&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">10&#44;11</span></a> The 5XSST is also useful for measuring fatigue caused by repeatedly sitting and standing and&#44; therefore&#44; is a surrogate measure of cardiopulmonary reserve&#46; The test was performed using a normal armchair&#44; with a seat at a height of 40<span class="elsevierStyleHsp" style=""></span>cm&#46; The test started with the subject sitting on the chair&#46; At the command of &#8220;1&#44; 2&#44; 3&#44; go&#8221;&#44; the subject stood up and sat down 5 times as fast as possible&#44; with their arms crossed on their chest&#46; All tests were performed using the same chair&#44; in similar ambient conditions&#46; Subjects were only allowed to use their hands to get up if they were unable to perform a repetition without assistance&#46; This was annotated in the data collection form&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Frailty</span><p id="par0060" class="elsevierStylePara elsevierViewall">The Canadian Study of Health and Ageing &#40;Clinical Frailty Scale&#41;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a> was used to measure frailty&#46; This is a fully validated&#44; easily administered scale in which subjects are assigned to one of 9 categories&#44; ranging from 1&#8211;very fit&#44; to 9&#8211;totally dependent&#44; terminally ill&#46; The scale considers various factors&#44; such as morbidity&#44; cognitive impairment and degree of dependence&#46; Frail patients are all those assigned to categories 4&#8211;9&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Emotional state</span><p id="par0065" class="elsevierStylePara elsevierViewall">Due to the psychological stress that an impending surgical intervention can cause&#44; we also evaluated each subject&#39;s emotional state&#46; For this purpose&#44; we used the 14-item Hospital Anxiety and Depression Scale&#44; &#40;HADS&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a> in which 7 items assess anxiety and 7 assess depression&#46; Each item is scored from 0 to 3&#44; so an individual can score between 0 and 21 for either anxiety or depression&#46; The HADS assesses the patient&#39;s status in the previous week&#46; In addition to quantitative assessment&#44; patients can be stratified into no anxiety or no depression if HADS scores are below 8&#59; possible or doubtful for scores between 8 and 10&#44; and probable or affirmative if they are 11 or higher&#46; For this study&#44; a cut-off score of 10 was chosen for each scale&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Other variables</span><p id="par0070" class="elsevierStylePara elsevierViewall">All the questionnaires were self-administered&#44; although patients were able to ask the interviewer to read and clarify the questions when necessary&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Sociodemographic variables &#40;alcohol and&#47;or tobacco consumption&#44; degree of dependency and presence of caregivers&#41;&#44; clinical variables &#40;body mass index&#44; presence of comorbidities&#44; American Society of Anesthesiologists &#91;ASA&#93; physical status classification&#41; and surgery-related variables &#40;type of surgery&#44; previous neoadjuvant treatments&#44; expected duration of surgery&#44; etc&#46;&#41; were also collected&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Finally&#44; a brief semi-structured interview was conducted to evaluate the patient&#39;s willingness to join a physical rehabilitation programme in the future&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Statistical analysis</span><p id="par0085" class="elsevierStylePara elsevierViewall">Descriptive variables are expressed as mean and standard deviation or frequency&#44; according to the type of variable&#46; Inter-group comparisons were performed using the Chi-square test in the case of qualitative variables and the Student&#39;s <span class="elsevierStyleItalic">t</span>-test for quantitative variables&#46; Statistical analysis was performed on SPSS<span class="elsevierStyleSup">&#174;</span> version 20&#46;0&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Results</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Characteristics of the study population</span><p id="par0090" class="elsevierStylePara elsevierViewall">A total of 140 patients met the inclusion criteria and were invited to participate in the study&#46; Only 8 of the patients scheduled for preoperative evaluation before elective general and gastrointestinal surgery requiring hospital admission were excluded &#40;3 due to language barrier or cognitive impairment&#44; 3 due to refusal to participate in the study&#44; and 2 due to physical incapacity to perform part of the tests&#41;&#46; The demographic characteristics of the sample are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Mean age was 60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15 years&#44; 56&#37; were males&#44; and 25&#37; of patients were ASA class <span class="elsevierStyleSmallCaps">III</span> or <span class="elsevierStyleSmallCaps">IV</span>&#46; Most &#40;78&#37;&#41; subjects came from the metropolitan area of Barcelona&#44; while the remaining 22&#37; lived in rural areas&#46; Nearly half &#40;49&#37;&#41; were scheduled for cancer surgery&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Physical activity level</span> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The level of physical activity in the previous week&#44; evaluated using the IPAQ questionnaire&#44; showed a very sedentary population&#44; with over two thirds of the patients &#40;70&#37;&#41; scoring 600 METs&#47;week&#44; with a mean of 667<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>180 METs&#47;week&#46; The average number of sedentary hours per day was 6&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>h&#44; while 21 individuals &#40;15&#37;&#41; were sedentary for 10<span class="elsevierStyleHsp" style=""></span>h or more per day&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Functional capacity</span> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Functional reserve&#44; estimated using the DASI questionnaire&#44; was low &#40;score<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>46&#41; in 68&#37; of study patients&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The 5XSST has only been validated in population groups aged 60 years or older&#46; In our population&#44; half the individuals were younger than 60 years&#44; and there are no reference values for subjects of this age&#46; For this reason&#44; we decided to use the reference values established for the 60&#8211;69 age group proposed by Bohannon&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a> Over half &#40;53&#37;&#41; of patients aged under the age of 60 took longer than predicted for their age group to perform the 5XSST&#44; showing diminished lower limb muscle strength &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; This proportion was even higher in the older age groups&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Frailty&#46;</span><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the distribution of patients according to the Canadian Study of Health and Ageing scale&#46; Very few &#40;18&#37;&#41; study patients were classified as frail under this scale&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Emotional state&#46;</span> The prospect of surgery elicited a clear anxiety-depressive syndrome in only 8&#37; of patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Determinants of low functional reserve</span><p id="par0120" class="elsevierStylePara elsevierViewall">Based on previous studies showing that a DASI score of over 46 is associated with an anaerobic threshold above 11<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;min&#44; the 140 study patients were divided into 2 groups according their DASI score&#58; low functional reserve &#40;DASI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>46&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>94&#41; and normal functional reserve &#40;DASI<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>46&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>46&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; Patients with low functional reserve were older &#40;66<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11 vs 48<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 years&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; and presented more comorbidities&#46; This group also included a higher percentage of ASA class <span class="elsevierStyleSmallCaps">III</span> and <span class="elsevierStyleSmallCaps">IV</span> &#40;34&#37; vs 7&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; than patients with normal functional reserve&#46; There were no significant differences with regard to sex&#44; body mass index or place of residence &#40;urban or rural&#41;&#46; The low functional reserve group included a higher percentage of patients scheduled for cancer surgery &#40;55&#37; vs 32&#37;&#41;&#44; although there were no differences in the percentage of patients who had previously received adjuvant chemotherapy and&#47;or radiotherapy&#46; Similarly&#44; the percentage of sedentary patient was significantly higher in the low functional reserve group &#40;75&#37; vs 56&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; While no patients in the normal functional reserve group had a total HADS score of over 20&#44; 13&#37; of patients with low functional reserve had a clear anxiety-depressive syndrome&#46; In addition&#44; mean scores for each scale were higher in this group&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">After the evaluation&#44; patients were asked to complete a short survey consisting of multiple-choice questions&#46; The results are shown in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#46; Nearly all &#40;90&#37;&#41; patients felt that a preoperative training programme might help improve their fitness for surgery&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">This study characterises&#44; from a functional perspective&#44; the surgical population in our setting&#44; namely the main tertiary level public hospital in an area of the city of Barcelona serving a population of 540&#44;000&#46; Our results highlight the low preoperative cardiopulmonary reserve in this population&#44; associated with a high proportion of frail patients and patients with a sedentary lifestyle&#46; Over two thirds of patients scheduled for general and gastrointestinal surgery presented low functional or cardiopulmonary reserve and had a sedentary lifestyle&#46; In view of the recently confirmed association between these factors and increased surgical morbidity and mortality&#44;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">2&#44;3</span></a> our findings are alarming&#44; and show the urgent need for corrective measures to improve surgical outcomes&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Despite advances in medicine&#44; postoperative complications continue to have a significant impact on clinical outcomes&#44; quality of life&#44; short- and medium-term survival&#44; and healthcare costs&#46; The importance of the problem is due&#44; in large part&#44; to the increase in surgical indications in high-risk population groups&#44; particularly elderly patients with important comorbidities&#46; As a recent multicentre European study has shown&#44; the postoperative mortality rate is currently 4&#37;&#44; although rates for individual countries vary greatly &#40;from 1&#46;2&#37; to 21&#46;5&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a> Even in procedures with a good outcome&#44; postoperative complications continue to be a major problem&#46; Therefore&#44; preoperative identification of high surgical risk patients enables clinicians to establish strategies for the prevention&#44; detection and early treatment of potential complications in order to reduce their incidence and severity&#44; and thus minimise their impact&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The extent of the surgery and the presence of cardiopulmonary comorbidities determine the onset of postoperative complications and the risk of death&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a> Various studies have shown that patients with low cardiopulmonary reserve are unable to respond to the increased metabolic demand arising from surgery&#44; and are more susceptible to complications&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a> In fact&#44; low preoperative exercise tolerance has been associated with a higher incidence of surgery-related complications and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a> Cardiopulmonary exercise testing is considered the gold standard for measuring an individual&#39;s aerobic capacity&#59; however&#44; these tests&#44; which are complex and costly&#44; are not routinely performed&#46; Fortunately&#44; several questionnaires and simple tests&#44; such as those used in our study&#44; are now available&#46; Despite their limitations&#44; these are extremely useful routine screening tools&#46; In our experience&#44; they can be completed in 15<span class="elsevierStyleHsp" style=""></span>min&#44; and can be administered by the nurses in the anaesthesiology department&#46; For example&#44; the DASI questionnaire&#44; recommended by the American Heart Association for preoperative assessment of functional status&#44; has shown good correlation with peak oxygen consumption &#40;a parameter derived from the cardiopulmonary exercise test&#41; in surgical patients&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a> Specifically&#44; Struthers et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a> showed that 100&#37; of patients with DASI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>46 were able to walk more than 360<span class="elsevierStyleHsp" style=""></span>m in the 6-min walk test &#40;a submaximal exercise test&#41; and had a peak oxygen consumption of over 15<span class="elsevierStyleHsp" style=""></span>ml O<span class="elsevierStyleInf">2</span>&#47;kg&#47;min&#44; and were therefore considered low risk for postoperative complications&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Furthermore&#44; a recent study<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a> in patients undergoing major oncological abdominal surgery showed that adequate activity level was the only independent factor associated with lower postoperative morbidity and mortality&#44; and is an even better predictor than age and comorbidities such as heart disease&#46; These data are consistent with studies evaluating physical activity&#44; aerobic capacity and speed of postoperative recovery after major surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">2&#44;3</span></a> The percentage of sedentarism observed in the study population is strikingly higher than previous published data for Spain&#46; In this regard&#44; it is important to emphasise that our patients were awaiting surgery&#44; so the very condition that indicated the need for surgery could have affected their general status and their lifestyle&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Frailty is a multidimensional syndrome characterised by a decline in the physiological reserve of organs and systems that places the individual at increased risk of disability and makes them vulnerable to external stresses&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">21</span></a> such as surgery&#46; Frailty has recently been shown to be a determining factor in the appearance postoperative complications&#44; exacerbation or worsening of underlying diseases&#44; longer hospital stay&#44; institutionalisation and death&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">22&#44;23</span></a> Advanced age and frailty are entirely different concepts and should not be confused&#44; even though the incidence of frailty obviously increases with age<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a> &#40;it is estimated to occur in around 7&#37; of individuals over the age of 65&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a> and the appearance of concomitant diseases&#44; more frequent in elderly individuals&#44; will accelerate the process&#46; Previous studies have shown that over 50&#37; of patients over 65 present concomitant diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">26</span></a> In fact&#44; the average age of our patients was 60 years &#40;half were less than 60&#41;&#44; and almost 1 in 5 met the criteria for frailty&#46; In addition&#44; the percentage of ASA <span class="elsevierStyleSmallCaps">III</span> &#8211; <span class="elsevierStyleSmallCaps">IV</span> patients was 4 times higher in the frail group&#44; and the incidence of sedentary lifestyle increased from 57&#37; in non-frail patients to 92&#37; in frail patients&#44; in other words&#44; almost all frail patients were sedentary&#46; An increase in life expectancy in developed countries will probably bring with it an increase in the number of frail individuals undergoing surgery&#46; However&#44; frailty can be reversed to a certain extent&#44; and studies have shown it can even be prevented through programmes that increase physical activity in the older population&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a> Although surgery is generally perceived as a major stressor&#44; the HADS questionnaire showed that few of our subjects presented preoperative anxiety or depression&#46; This could indicate that the questionnaire&#44; which is designed for hospitalised patients&#44; is not the most appropriate tool for measuring pre-surgical stress&#46; The association between low functional reserve and anxiety and depression&#44; however&#44; is striking&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Based on the hypothesis that increased physical activity and training can improve the sedentarism&#44; frailty and low functional reserve that characterises this population&#44; pre-habilitation is a highly promising preventive intervention that can not only prove clinically effective&#44; but also reduce healthcare costs&#46; Pre-habilitation consists of a physical training programme combined with improvements in lifestyle that is followed by surgical patients in the preoperative period to improve their aerobic capacity&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">28&#44;29</span></a> The aim is to increase the patient&#39;s functional capacity to overcome the consequences of surgical stress&#44; thus reducing the incidence and severity of postoperative complications&#46; Interestingly&#44; our survey shows that 90&#37; of patients admit that a training programme could improve their pre-surgical physical condition&#44; and expressed their willingness to receive help in this regard&#46; Participating in such a programme could have a beneficial effect not only in the short term &#40;surgical outcomes&#41;&#44; but also in the long term &#40;change in lifestyle&#41;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Obviously&#44; our small sample size limits the strength of the conclusions drawn in this study&#59; nevertheless&#44; our randomly selected population reveals a real problem of our society&#58; the high rate of sedentarism and frailty&#46; Enlarging the sample to include patients scheduled for different surgeries would give clearer insight into the determining factors and potential strategies&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In conclusion&#44; the present study shows that the population of a tertiary hospital in a city like Barcelona is characterised by a high &#40;&#62;60&#37;&#41; prevalence of low cardiopulmonary reserve and sedentarism&#46; Both these factors are associated with a poor surgical prognosis&#46; The systematic use of simple tests and questionnaires to identify risk groups and plan the appropriate preoperative treatment and implement pre-habilitation programmes should form part of routine preoperative care&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Ethical disclosures</span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Protection of human and animal subjects</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the responsible Clinical Research Ethics Committee and in accordance with those of the World Medical Association and the Helsinki Declaration&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Confidentiality of data</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors declare that they have adhered to the protocols of their centre of work on patient data publication&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Right to privacy and informed consent</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors must have obtained the informed consent of the patients and&#47;or subjects mentioned in the article&#46; The author for correspondence must be in possession of this document&#46;</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Conflict of interest</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest&#46;</p></span></span>"
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            0 => "Actividad f&#237;sica"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Frailty and low physical activity and cardiorespiratory reserve are related to higher perioperative morbimortality&#46; The crucial step in improving the prognosis is to implement specific measures to optimise these aspects&#46; It is critical to know the magnitude of the problem in order to implement preoperative optimisation programmes&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To characterise surgical population in a university hospital&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">All patients undergoing preoperative evaluation for abdominal surgery with admission were prospectively included during a 3-month period&#46; Level of physical activity&#44; functional capacity&#44; frailty and emotional state were assessed using score tests&#46; Additionally&#44; physical condition was evaluated using <span class="elsevierStyleItalic">5 Times Sit-to-Stand Test</span>&#46; Demographic&#44; clinical and surgical data were collected&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">One hundred and forty patients were included &#40;60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>yr-old&#44; 56&#37; male&#44; 25&#37; ASA III or IV&#41;&#46; Forty-nine percent of patients were proposed for oncologic surgery and 13&#37; of which had received neoadjuvant treatment&#46; Seventy percent of patients presented a low functional capacity and were sedentary&#46; Eighteen percent of patients were considered frail and more than 50&#37; completed the <span class="elsevierStyleItalic">5 Times Sit-to-Stand Test</span> at a higher time than the reference values adjusted to age and sex&#46; Advanced age&#44; ASA III&#47;<span class="elsevierStyleSmallCaps">IV</span>&#44; sedentarism&#44; frailty and a high level of anxiety and depression were related to a lower functional capacity&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The surgical population of our area has a low functional reserve and a high index of sedentary lifestyle and frailty&#44; predictors of postoperative morbidity&#46; It is mandatory to implement preoperative measures to identify population at risk and prehabilitation programmes&#44; considered highly promising preventive interventions towards improving surgical outcome&#46;</p></span>"
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            "titulo" => "Introduction"
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            "titulo" => "Objective"
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          2 => array:2 [
            "identificador" => "abst0015"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Una baja reserva cardiorrespiratoria&#44; un bajo nivel de actividad f&#237;sica y la fragilidad se relacionan con una mayor morbimortalidad perioperatoria&#46; Implementar medidas para optimizar estos aspectos es clave para mejorar el pron&#243;stico&#46; Es fundamental conocer la magnitud del problema para dimensionar los programas de optimizaci&#243;n preoperatoria&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Caracterizar la poblaci&#243;n quir&#250;rgica de un hospital universitario de nivel terciario&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron prospectivamente todos los pacientes sometidos a evaluaci&#243;n preoperatoria para cirug&#237;a digestiva con ingreso durante 3 meses&#46; Se evalu&#243; el nivel de actividad f&#237;sica&#44; la capacidad funcional&#44; la fragilidad y el estado emocional&#44; y se realiz&#243; un test de medici&#243;n del estado f&#237;sico &#40;<span class="elsevierStyleItalic">5 Times Sit-to-Stand Test</span>&#41;&#46; Se recogieron datos demogr&#225;ficos&#44; cl&#237;nicos y relacionados con la cirug&#237;a&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 140 pacientes &#40;60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15 a&#241;os&#44; 56&#37; varones&#44; 25&#37; ASA <span class="elsevierStyleSmallCaps">III</span> o <span class="elsevierStyleSmallCaps">IV</span>&#41;&#46; El 49&#37; estaban propuestos para cirug&#237;a oncol&#243;gica y un 13&#37; hab&#237;a recibido neoadyuvancia&#46; El 70&#37; de los pacientes presentaban una capacidad funcional reducida y eran sedentarios&#46; Un 18&#37; fueron considerados fr&#225;giles y m&#225;s de un 50&#37; completaron el <span class="elsevierStyleItalic">5 Times Sit-to-Stand Test</span> en un tiempo superior a los valores de referencia&#46; La edad avanzada&#44; el ASA <span class="elsevierStyleSmallCaps">III</span>&#47;<span class="elsevierStyleSmallCaps">IV</span>&#44; el sedentarismo&#44; la fragilidad y un nivel de ansiedad&#47;depresi&#243;n elevado se relacionaron con una menor capacidad funcional&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La poblaci&#243;n quir&#250;rgica de nuestro entorno tiene una baja reserva funcional y un elevado &#237;ndice de sedentarismo y fragilidad&#44; factores asociados a un peor pron&#243;stico quir&#250;rgico&#46; Urge implementar medidas preoperatorias para identificar la poblaci&#243;n de riesgo y programas de prehabilitaci&#243;n considerados estrategias de optimizaci&#243;n preoperatoria con gran potencial&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Dana F&#44; Capit&#225;n D&#44; Ubr&#233; M&#44; Herv&#225;s A&#44; Risco R&#44; Mart&#237;nez-Pall&#237; G&#46; Actividad f&#237;sica y fragilidad como indicadores de reserva cardiorrespiratoria y predictores del pron&#243;stico quir&#250;rgico&#58; caracterizaci&#243;n de la poblaci&#243;n quir&#250;rgica en cirug&#237;a general y digestiva&#46; Rev Esp Anestesiol Reanim&#46; 2018&#59;65&#58;5&#8211;12&#46;</p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">ASA&#58; American Society of Anesthesiologists&#59; BMI&#58; body mass index&#59; M&#58; men&#59; SD&#58; standard deviation&#59; W&#58; women&#46;</p>"
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Age in years&#44; mean</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">SD &#40;range&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15 &#40;18&#8211;92&#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">Sex &#40;M&#47;W&#41;&#44; &#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56&#47;44&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">BMI&#44; mean</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">SD &#40;range&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7 &#40;18&#8211;54&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Smoking history&#44; &#37;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Active smoker</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Former smoker</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Never smoker</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Clinical characteristics&#44; &#37;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">ASA III-IV</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Comorbidities</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Cardiovascular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Respiratory&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Diabetes mellitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Dependency&#44; &#37;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Requires full-time care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Requires part-time care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Occupation&#44; &#37;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Active&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Sick leave&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Retired&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Student&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Domestic work&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Unemployed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Type of surgery&#44; &#37;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Oncological&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Previous adjuvant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Type of surgery</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Colorectal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Hepatobiliary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Gastroesophageal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Endocrine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Abdominal wall&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Pancreatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">CHSA&#58; Canadian Study of Health and Ageing&#44; Clinical Frailty Scale&#59; DASI&#58; Duke Activity Status Index&#59; HADS&#58; Hospital Anxiety and Depression Scale&#59; IPAQ&#58; International Physical Activity Questionnaire&#59; MET&#58; metabolic equivalent&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Physical Activity &#40;IPAQ&#41;&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Sedentary &#40;&#60;600</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">MET&#47;wk&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96 &#40;69&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Moderate physical activity &#40;600&#8211;3000</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">METs&#47;wk&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42 &#40;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Intense physical activity &#40;&#62;3000</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">METs&#47;wk&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Functional reserve&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">DASI score</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">46 &#40;low reserve&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">94 &#40;68&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">5 Times Sit-to-Stand Test&#44; patients above reference value</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#60;60 years &#40;11&#46;4<span class="elsevierStyleHsp" style=""></span>s&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34 &#40;53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>60&#8211;69 years &#40;11&#46;4<span class="elsevierStyleHsp" style=""></span>s&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34 &#40;81&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>70&#8211;79 years &#40;12&#46;6<span class="elsevierStyleHsp" style=""></span>s&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20 &#40;91&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>80&#8211;89 years &#40;14&#46;8<span class="elsevierStyleHsp" style=""></span>s&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;60&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#62;89 years &#40;14&#46;8<span class="elsevierStyleHsp" style=""></span>s&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>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 &#40;67&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Frailty &#40;CHSA&#41;&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Patients scoring</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8805;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">4</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25 &#40;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Emotional state &#40;HADS&#41;&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Anxiety&#47;depression &#40;HADS &#62; 20&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;8&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Level of physical activity&#44; functional reserve&#44; frailty and emotional state&#46;</p>"
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        "etiqueta" => "Table 3"
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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  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Canadian Study of Health and Ageing&#44; Clinical Frailty Scale</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Score&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">Characteristics&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">n &#40;&#37;&#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">1&#46; Very fit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Active&#44; energetic&#44; no concurrent diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;7&#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">2&#46; Well&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No symptomatology&#44; occasionally active&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51 &#40;36&#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">3&#46; Managing well&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Well controlled disease&#44; not regularly active beyond routine walking&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55 &#40;39&#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">4&#46; Vulnerable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Symptomatic concomitant disease limiting activity&#44; independent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;11&#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">5&#46; Mildly frail&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Needs help with instrumental activities of daily living&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;6&#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">6&#46; Moderately frail&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dependent for all activities outside and inside the home &#40;bathing&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;1&#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">7&#46; Severely frail&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Completely dependent for personal care&#44; not at high risk of dying &#40;6 months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&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">8&#46; Very Severely Frail&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Completely dependent&#44; approaching the end of life&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&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">9&#46; Terminally Ill&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Life expectancy<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>6 months&#44; but not otherwise evidently frail&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">5XSST&#58; 5 Times Sit-to-Stand Test&#59; A&#38;D&#58; anxiety and depression&#59; ASA&#58; American Society of Anesthesiologists&#59; BMI&#58; body mass index&#59; CHSA&#58; Canadian Study of Health and Ageing&#44; Clinical Frailty Scale&#59; DASI&#58; Duke Activity Status Index&#59; HADS&#58; Hospital Anxiety and Depression Scale&#59; M&#58; men&#59; ns&#58; not significant&#59; SD&#58; standard deviation&#59; W&#58; women&#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">Patients with low functional reserve<br>&#40;DASI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>46&#41;<br>&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>94&#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">Patients with adequate functional reserve<br>&#40;DASI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>46&#41;<br>&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>46&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&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 in years&#44; mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">66<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">48<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;05&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">Sex&#44; M&#47;W&#44; n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">53&#47;41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#47;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ns&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">BMI in kg&#47;m<span class="elsevierStyleSup">2</span>&#44; mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ns&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 III-IV&#44; n &#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">32 &#40;34&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;05&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">Oncological surgery&#44; n &#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">52 &#40;55&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16 &#40;32&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;05&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">Neoadyuvant therapy&#44; n &#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">12 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ns&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">Sedentary lifestyle&#44; n &#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">69 &#40;73&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27 &#40;58&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;05&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">5XSST above average&#44; n &#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">74 &#40;79&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21 &#40;46&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;05&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">Frail CHSA<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>4&#44; n &#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">25 &#40;27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;05&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">HADS &#40;A&#38;D&#41;<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>20&#44; n &#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">12 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;05&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">Anxiety scale score<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>10&#44; n &#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">19 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;05&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">Depression scale score<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>10&#44; n &#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">5 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Patient characteristics according to functional reserve&#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="left" valign="top" scope="col" style="border-bottom: 2px solid black">Questions&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">Yes&#44; &#37;&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="elsevierStyleItalic">Do you think that improving your fitness through an exercise programme would be useful to prepare for your surgery&#63;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">If yes&#44; select the option that best describes how you would prefer to follow such a programme</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>On your own&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Outside the hospital&#44; following instructions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>In the hospital&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Survey on joining a pre-habilitation programme&#46;</p>"
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      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
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        0 => array:2 [
          "identificador" => "bibs0015"
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                0 => array:2 [
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                      "titulo" => "Postoperative fatigue"
                      "autores" => array:1 [
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