Estimated metabolic equivalents of task do not correlate with the maximal oxygen consumption of patients undergoing lung resection surgery | Revista Española de Anestesiología y Reanimación (English Edition)

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Nieves-Alonso, R.M. Méndez Hernández, F. Ramasco Rueda, A. Planas Roca" "autores" => array:4 [ 0 => array:4 [ "nombre" => "J.M." "apellidos" => "Nieves-Alonso" "email" => array:1 [ 0 => "jesusmna@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "R.M." "apellidos" => "Méndez Hernández" ] 2 => array:2 [ "nombre" => "F." "apellidos" => "Ramasco Rueda" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Planas Roca" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Universitario de La Princesa, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Los equivalentes metabólicos estimados no se relacionan con el consumo máximo de oxígeno calculado en pacientes candidatos a cirugía de resección pulmonar" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1301 "Ancho" => 2294 "Tamanyo" => 135829 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Distribution of the results of the MET evaluation in the pre-anaesthesia consultation and in the stress test laboratory. METSe: metabolic equivalents quantified in the pre-anaesthesia consultation; METVO2: metabolic equivalents calculated by ergometry." ] ] ] "textoCompleto" => "IntroductionQuantifying maximal oxygen uptake (VO2max) is a pivotal steps in the preoperative evaluation of patients scheduled for major pulmonary resection (lobectomy, bilobectomy, pneumonectomy)<a class="elsevierStyleCrossRef" href="#bib0005">1</a>. VO2max is usually measured in the stress test laboratory by means of physical exercise tests, and values of less that 12 mL/kg/min have been associated with increased postoperative morbidity and mortality<a class="elsevierStyleCrossRef" href="#bib0010">2</a>. Unfortunately, laboratory-based physical exercise tests are expensive, require specialized personnel and equipment, and often delay surgery. This is why some clinicians try to quantify exercise tolerance during the pre-anaesthesia evaluation by asking patients to rate the intensity and frequency of their daily physical activities<a class="elsevierStyleCrossRef" href="#bib0015">3</a>.Metabolic equivalents (MET) are a physiological measure that represents the metabolic cost of an activity of daily living, where 1 MET is equivalent to the oxygen consumed while sitting quietly (3.5 mL/kg/min). Following the recommendations of the 2014 European and American guidelines for preoperative cardiovascular assessment in noncardiac surgery, METs are usually estimated during the pre-anaesthesia evaluation by asking the patient to rate their ability to perform physical activities<a class="elsevierStyleCrossRefs" href="#bib0020">4,5</a>. According to these guidelines, patients with <4 METs (functional class IV), particularly those scheduled for thoracic surgery, are more likely to present perioperative complications.However, the METs quantified in the pre-anaesthesia evaluation (METSe) by means of questionnaires do not always tally with the METs obtained by calculating VO2max in the stress test laboratory (METVO2)<a class="elsevierStyleCrossRefs" href="#bib0015">3,6</a>.The aim of this study is to measure the degree of concordance between METSe and METVO2 in patients scheduled for lung resection surgery, and to determine whether METSe is reliable enough to dispense with stress testing in these patients.Materials and methodsRetrospective, observational study. We collected data from the computerized medical records of patients scheduled for lung resection surgery who attended the pre-anaesthesia consultation and subsequently underwent tests to measure VO2max. The study was conducted over an 18-month period between January 2017 and June 2018.Following the recommendations of the European and American guidelines for preoperative cardiovascular assessment in noncardiac surgery, METs were estimated during the pre-anaesthesia consultation by asking patients to rate their ability to perform physical activities<a class="elsevierStyleCrossRef" href="#bib0025">5</a>. Examples of the physical activities used in consultation have been published and reviewed elsewhere<a class="elsevierStyleCrossRef" href="#bib0035">7</a>, and are shown, together with their corresponding 4 functional classes, in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>VO2max was measured using an incremental cycle ergometer test performed in the stress test laboratory (maximum incremental stress test) following the standard protocol for the preoperative study of patients scheduled for lung resection surgery. METVO2 measurements were obtained using the following equation:<elsevierMultimedia ident="eq0005"></elsevierMultimedia>The preoperative stress test was performed according to the criteria used by the thoracic surgery service. In our hospital, this test is routinely performed on patients scheduled for major lung resection surgery who present forced expiratory volume in 1 s (FEV1) and/or diffusing capacity of carbon monoxide (DLCO) of less than 80% of predicted in a preoperative plethysmography study. The pre-anaesthesia evaluation and cycle ergometer test was performed between 0 and 14 days after the patient had been scheduled for surgery.METVO2 was divided into the same 4 functional classes as METSe. The METSe and METVO2 variables were then dichotomised (<4 METs/≥4 METs) in order to calculate the sensitivity and specificity of METSe quantifications using the METVO2 as the gold standard.Statistical analysisThe Kolmogorov-Smirnov test was used to confirm the normal distribution of the data. Normally distributed continuous variables are expressed as mean ± standard deviation (SD). Categorical variables are expressed as numbers and percentages. Cohen's kappa coefficient was used to determine the concordance between both MET calculation methods (pre-anaesthesia evaluation and ergometry). Then a cross table was created to calculate the sensitivity and specificity of METSe using METVO2 as the gold standard. A value of P < .05 was considered statistically significant. Data were analysed using SPSS® version 26.0 (SPSS Inc., Chicago, IL, USA).The study was approved by the Drug Research Ethics Committee (CEIm) of the Hospital Universitario de La Princesa (Ref.: 3569/20-12-18, CEIm minutes 22/18). Given the nature of the study (retrospective chart review), the need for informed consent was waived.ResultsA total of 104 patients were included in the study, of whom 25 (24%) were women. Mean age was 65.1 years (± 9.8). Mean VO2max was 15.8 (±3.9) mL/kg/min, equivalent to a mean METVO2 of 4.51 (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>In 26 (25%) patients, METSe was concordant with METVO2 (κ = −0.107; P = .02). In the remaining patients (78), METSe overestimated functional capacity: 9 patients reported functional class 1 (>10 METs) in the pre-anaesthesia evaluation but presented functional class III (4−6 METs) during the stress test; 46 patients reported functional class II (7−10 METs) in the pre-anaesthesia evaluation but presented functional class III or IV (<4 METs) in the stress test; and 23 patients reported functional class III in the pre-anaesthesia evaluation but showed functional class IV in the stress test. None of the study patients showed METVO2 ≥ 7. The bar chart in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> compares the functional capacity estimated in the pre-anaesthesia consultation and that calculated in the stress test laboratory.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>In our sample, 30.7% (n = 32) patients had <4 METVO2. Only 1 patient with METVO2 < 4 (1/32) received the same classification in the pre anaesthesia consultation. The sensitivity and specificity of METSe for detecting patients with <4 METVO2 was 3.12% and 100%, respectively.DiscussionThe results of this study show that calculating metabolic equivalents in the pre-anaesthesia consultation overestimates the functional capacity of patients scheduled for lung resection surgery when compared with ergometry-based METs.Measuring functional capacity is a pivotal step in the preoperative evaluation, and in lung resection surgery in particular VO2max can determine the extent of the resection. In our sample, 32 of the 104 patients were classed as high risk according to METVO2, but only 1 was correctly classed on the basis of the pre-anaesthesia consultation. This shows that estimating functional capacity on the basis of a questionnaire has a sensitivity of just 3.12% compared to ergometry-based estimations.Several authors have attempted to describe reliable methods for estimating functional capacity during the pre-anaesthesia evaluation without the need for complex and expensive tests. Most of the tests studied have consisted of questionnaires designed to quantify the patient's physical status, such as the Duke Activity Status Index (DASI) or similar tools<a class="elsevierStyleCrossRef" href="#bib0040">8</a>. The problem with these questionnaires is that they rely on the patient’s or doctor’s subjective opinion, and studies have found that validated questionnaires tend to overestimate functional capacity<a class="elsevierStyleCrossRef" href="#bib0045">9</a>. Our results are consistent with those of other authors, such as Wijeysundera et al.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>, who found that the anaesthesiologist’s subjective assessment of patients scheduled for major surgery in the pre-anaesthesia evaluation had 19.2% sensitivity and a 94.7% specificity to detect patients with <4 METs compared with ergometry. Stokes et al.<a class="elsevierStyleCrossRef" href="#bib0050">10</a>, meanwhile, compared METSe with estimates obtained using the DASI questionnaire administered during the preoperative evaluation of 204 patients scheduled for major surgery, and found the 53.4% of patients were quantified as <4 METs by the DASI vs. 8% by METSe; however, the authors did not perform cardiopulmonary function tests on any patients in this study. In our sample, METSe correlated adequately with METVO2 in only 26 patients (25%) (κ = −0.107).Our study has several limitations. First, it is a retrospective chart review. Second, our study population included only patients scheduled for lung resection surgery, and therefore our results cannot be extrapolated to other surgical populations. Finally, given the absence of detailed data regarding postoperative complications, we were unable to analyse whether subjective or objective functional capacity is clinically relevant in predicting surgical and cardiorespiratory complications.In conclusion, the simplified, subjective method of assessing functional capacity does not correlate with VO2max, and therefore should not replace objective testing in patients scheduled for lung resection surgery.FundingThe authors declare that they have not received funding for this study.Conflict of interestsThe authors have no conflict of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1769540" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1554945" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1769539" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1554946" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-11-16" "fechaAceptado" => "2021-01-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1554945" "palabras" => array:7 [ 0 => "Thoracic surgery" 1 => "Thoracic anaesthesia" 2 => "Pre-anaesthesia" 3 => "Maximal oxygen consumption" 4 => "Functional capacity" 5 => "Ergometry" 6 => "Metabolic equivalent" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1554946" "palabras" => array:7 [ 0 => "Cirugía torácica" 1 => "Anestesia torácica" 2 => "Preanestesia" 3 => "Consumo máximo de oxígeno" 4 => "Capacidad funcional" 5 => "Ergometría" 6 => "Equivalente metabólico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "Background and objectiveMetabolic equivalent of task (MET) is a physiological measure that represents the metabolic cost of an activity of daily living. One MET is equivalent to the resting metabolic rate. METs can be estimated by questionnaires or calculated by measuring maximal oxygen uptake (VO2max). The aim of this study is to determine whether METs estimated in the pre-consultation (METse) correlates with METs calculated from VO2max (METsVO2). Patients and methodsRetrospective observational study in patients scheduled for lung resection surgery. The estimation of METs was obtained in the pre-consultation according to the 2014 European and American guidelines for preoperative cardiovascular assessment in non-cardiac surgery. VO2max was calculated in the ergometry laboratory. ResultsA total of 104 patients were included in the study, of whom 25 (24%) were female. The mean age was 65.1 years (±9.8). In 26 patients (25%), the METse classification correlated with METsVO2 (κ = −0.107 P = .02). In the remaining patients, METse overestimated functional capacity measured by ergometry (METse > METsVO2). ConclusionsSubjective assessment overestimates functional capacity and should not replace objective testing in patients scheduled for lung resection surgery." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "Antecedentes y objetivoLos equivalentes metabólicos (METS) son una medida fisiológica que representa el coste metabólico de una actividad de la vida cotidiana. Un MET equivale al consumo metabólico en reposo. Los METS se pueden estimar mediante cuestionarios o calcular a partir de la medida del máximo consumo de oxígeno (VO2max). El objetivo de este estudio es determinar si existe concordancia entre los METS estimados en la consulta de preanestesia (METSe) con los METS calculados a partir de VO2max (METSVO2). Pacientes y métodosEstudio observacional retrospectivo en pacientes candidatos a cirugía de resección pulmonar. La estimación de los METSe se obtuvo en la consulta de preanestesia de acuerdo a las guías europeas y americanas de valoración cardiovascular preoperatoria en cirugía no cardiaca de 2014. El VO2max se calculó en el laboratorio de ergometría. ResultadosSe incluyeron un total de 104 pacientes en el estudio, de los que 25 (24%) eran mujeres. La edad media fue de 65,1 años (±9,8). Veintiséis pacientes (25%) presentaron una clasificación concordante de METSe con METSVO2 (κ = −0,107 P = ,02). En el resto de los pacientes, los METSe sobreestimaron la capacidad funcional medida por ergometría (METSe > METS VO2). ConclusionesLa valoración subjetiva sobreestima la capacidad funcional y no debe reemplazar la realización de pruebas objetivas en pacientes propuestos para cirugía de resección pulmonar." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Nieves-Alonso JM, Méndez Hernández RM, Ramasco Rueda F, Planas Roca A. Los equivalentes metabólicos estimados no se relacionan con el consumo máximo de oxígeno calculado en pacientes candidatos a cirugía de resección pulmonar. Rev Esp Anestesiol Reanim. 2022;69:437–441." ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1301 "Ancho" => 2294 "Tamanyo" => 135829 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Distribution of the results of the MET evaluation in the pre-anaesthesia consultation and in the stress test laboratory. METSe: metabolic equivalents quantified in the pre-anaesthesia consultation; METVO2: metabolic equivalents calculated by ergometry." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Source: the ACC/AHA Perioperative Cardiovascular Evaluation Guidelines for Noncardiac Surgery (Fleisher et al.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>) and the second revision of the compendium of physical activities (Ainsworth et al.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>)." "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Functional capacity \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Metabolic equivalents (METs) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Example of activity \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Class1 - Excellent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vigorous activity (running, competitive sport) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Class II - Good \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7−10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Climbing stairs with shopping bags, moderate exercise (paddle tennis, basketball, swimming, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Class III - Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4−6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Climbing one flight of stairs, strenuous home activities \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Class IV - Poor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unable to climb one flight of stairs \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Functional capacity estimated on the basis of daily physical activities, expressed in metabolic equivalents." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "BMI: body mass index; DLCO: diffusing capacity for carbon monoxide; FEV1: forced expiratory volume in1 second; METSe: metabolic equivalents quantified in the pre-anaesthesia consultation; METVO2: metabolic equivalents calculated by ergometry; SD: standard deviation; VO2max: maximal oxygen uptake." "tablatextoimagen" => array:1 [ 0 => array:1 [ "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="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Demographic variables</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age (years); mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65.1 (9.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Women; n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 (24) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Men; n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">79 (76) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BMI (kg/m2); mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27.8 (5.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">FEV1; % of predicted (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">79.2 (20.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DLCO; % of predicted (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">83.3 (19.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VO2max; (mL/kg/min) (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15.8 (3.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">METSe; n (%)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4−6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48 (46.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7−10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46 (44.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (8.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">METVO2; n (%)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 (30.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4−6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">72 (69.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7−10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Patient demographics." ] ] 3 => array:5 [ "identificador" => "eq0005" "tipo" => "MULTIMEDIAFORMULA" "mostrarFloat" => false "mostrarDisplay" => true "Formula" => array:1 [ "Quimica" => "METVO2 = VO2max/3.5." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "BTS guidelines: guidelines on the selection of patients with lung cancer for surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "British Thoracic Society; 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"fecha" => "2001" "volumen" => "56" "paginaInicial" => "89" "paginaFinal" => "108" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11209097" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Exercise testing in the evaluation of patients at high risk for complications from lung resection" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "R.C. Morice" 1 => "M.B. Ryan" 2 => "J. Putnam" 3 => "M. Ali" 4 => "J.A. Roth" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.101.2.356" "Revista" => array:6 [ "tituloSerie" => "Chest." 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Estimated metabolic equivalents of task do not correlate with the maximal oxygen consumption of patients undergoing lung resection surgery

Los equivalentes metabólicos estimados no se relacionan con el consumo máximo de oxígeno calculado en pacientes candidatos a cirugía de resección pulmonar

J.M. Nieves-Alonso

Corresponding author

jesusmna@gmail.com

Corresponding author.

, R.M. Méndez Hernández, F. Ramasco Rueda, A. Planas Roca

Servicio de Anestesiología y Reanimación, Hospital Universitario de La Princesa, Madrid, Spain

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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Distribution of the results of the MET evaluation in the pre-anaesthesia consultation and in the stress test laboratory&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">METSe&#58; metabolic equivalents quantified in the pre-anaesthesia consultation&#59; MET<span class="elsevierStyleInf">VO2</span>&#58; metabolic equivalents calculated by ergometry&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Quantifying maximal oxygen uptake &#40;VO<span class="elsevierStyleInf">2</span>max&#41; is a pivotal steps in the preoperative evaluation of patients scheduled for major pulmonary resection &#40;lobectomy&#44; bilobectomy&#44; pneumonectomy&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; VO<span class="elsevierStyleInf">2</span>max is usually measured in the stress test laboratory by means of physical exercise tests&#44; and values of less that 12&#8239;mL&#47;kg&#47;min have been associated with increased postoperative morbidity and mortality<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; Unfortunately&#44; laboratory-based physical exercise tests are expensive&#44; require specialized personnel and equipment&#44; and often delay surgery&#46; This is why some clinicians try to quantify exercise tolerance during the pre-anaesthesia evaluation by asking patients to rate the intensity and frequency of their daily physical activities<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Metabolic equivalents &#40;MET&#41; are a physiological measure that represents the metabolic cost of an activity of daily living&#44; where 1 MET is equivalent to the oxygen consumed while sitting quietly &#40;3&#46;5&#8239;mL&#47;kg&#47;min&#41;&#46; Following the recommendations of the 2014 European and American guidelines for preoperative cardiovascular assessment in noncardiac surgery&#44; METs are usually estimated during the pre-anaesthesia evaluation by asking the patient to rate their ability to perform physical activities<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a>&#46; According to these guidelines&#44; patients with &#60;4 METs &#40;functional class IV&#41;&#44; particularly those scheduled for thoracic surgery&#44; are more likely to present perioperative complications&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">However&#44; the METs quantified in the pre-anaesthesia evaluation &#40;METSe&#41; by means of questionnaires do not always tally with the METs obtained by calculating VO<span class="elsevierStyleInf">2</span>max in the stress test laboratory &#40;MET<span class="elsevierStyleInf">VO2</span>&#41;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;6</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of this study is to measure the degree of concordance between METSe and MET<span class="elsevierStyleInf">VO2</span> in patients scheduled for lung resection surgery&#44; and to determine whether METSe is reliable enough to dispense with stress testing in these patients&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">Retrospective&#44; observational study&#46; We collected data from the computerized medical records of patients scheduled for lung resection surgery who attended the pre-anaesthesia consultation and subsequently underwent tests to measure VO<span class="elsevierStyleInf">2</span>max&#46; The study was conducted over an 18-month period between January 2017 and June 2018&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Following the recommendations of the European and American guidelines for preoperative cardiovascular assessment in noncardiac surgery&#44; METs were estimated during the pre-anaesthesia consultation by asking patients to rate their ability to perform physical activities<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; Examples of the physical activities used in consultation have been published and reviewed elsewhere<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#44; and are shown&#44; together with their corresponding 4 functional classes&#44; in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">VO<span class="elsevierStyleInf">2</span>max was measured using an incremental cycle ergometer test performed in the stress test laboratory &#40;maximum incremental stress test&#41; following the standard protocol for the preoperative study of patients scheduled for lung resection surgery&#46; MET<span class="elsevierStyleInf">VO2</span> measurements were obtained using the following equation&#58;<elsevierMultimedia ident="eq0005"></elsevierMultimedia></p><p id="par0040" class="elsevierStylePara elsevierViewall">The preoperative stress test was performed according to the criteria used by the thoracic surgery service&#46; In our hospital&#44; this test is routinely performed on patients scheduled for major lung resection surgery who present forced expiratory volume in 1&#8239;s &#40;FEV1&#41; and&#47;or diffusing capacity of carbon monoxide &#40;DLCO&#41; of less than 80&#37; of predicted in a preoperative plethysmography study&#46; The pre-anaesthesia evaluation and cycle ergometer test was performed between 0 and 14 days after the patient had been scheduled for surgery&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">MET<span class="elsevierStyleInf">VO2</span> was divided into the same 4 functional classes as METSe&#46; The METSe and MET<span class="elsevierStyleInf">VO2</span> variables were then dichotomised &#40;&#60;4 METs&#47;&#8805;4 METs&#41; in order to calculate the sensitivity and specificity of METSe quantifications using the MET<span class="elsevierStyleInf">VO2</span> as the gold standard&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical analysis</span><p id="par0050" class="elsevierStylePara elsevierViewall">The Kolmogorov-Smirnov test was used to confirm the normal distribution of the data&#46; Normally distributed continuous variables are expressed as mean&#8239;&#177;&#8239;standard deviation &#40;SD&#41;&#46; Categorical variables are expressed as numbers and percentages&#46; Cohen&#39;s kappa coefficient was used to determine the concordance between both MET calculation methods &#40;pre-anaesthesia evaluation and ergometry&#41;&#46; Then a cross table was created to calculate the sensitivity and specificity of METSe using MET<span class="elsevierStyleInf">VO2</span> as the gold standard&#46; A value of <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;05 was considered statistically significant&#46; Data were analysed using SPSS&#174; version 26&#46;0 &#40;SPSS Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The study was approved by the Drug Research Ethics Committee &#40;CEIm&#41; of the Hospital Universitario de La Princesa &#40;Ref&#46;&#58; 3569&#47;20-12-18&#44; CEIm minutes 22&#47;18&#41;&#46; Given the nature of the study &#40;retrospective chart review&#41;&#44; the need for informed consent was waived&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">A total of 104 patients were included in the study&#44; of whom 25 &#40;24&#37;&#41; were women&#46; Mean age was 65&#46;1 years &#40;&#177; 9&#46;8&#41;&#46; Mean VO<span class="elsevierStyleInf">2</span>max was 15&#46;8 &#40;&#177;3&#46;9&#41;&#8239;mL&#47;kg&#47;min&#44; equivalent to a mean MET<span class="elsevierStyleInf">VO2</span> of 4&#46;51 &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">In 26 &#40;25&#37;&#41; patients&#44; METSe was concordant with MET<span class="elsevierStyleInf">VO2</span> &#40;&#954;&#8239;&#61;&#8239;&#8722;0&#46;107&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#46;02&#41;&#46; In the remaining patients &#40;78&#41;&#44; METSe overestimated functional capacity&#58; 9 patients reported functional class 1 &#40;&#62;10 METs&#41; in the pre-anaesthesia evaluation but presented functional class III &#40;4&#8722;6 METs&#41; during the stress test&#59; 46 patients reported functional class II &#40;7&#8722;10 METs&#41; in the pre-anaesthesia evaluation but presented functional class III or IV &#40;&#60;4 METs&#41; in the stress test&#59; and 23 patients reported functional class III in the pre-anaesthesia evaluation but showed functional class IV in the stress test&#46; None of the study patients showed MET<span class="elsevierStyleInf">VO2</span>&#8239;&#8805;&#8239;7&#46; The bar chart in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> compares the functional capacity estimated in the pre-anaesthesia consultation and that calculated in the stress test laboratory&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">In our sample&#44; 30&#46;7&#37; &#40;n&#8239;&#61;&#8239;32&#41; patients had &#60;4 MET<span class="elsevierStyleInf">VO2</span>&#46; Only 1 patient with MET<span class="elsevierStyleInf">VO2</span>&#8239;&#60;&#8239;4 &#40;1&#47;32&#41; received the same classification in the pre anaesthesia consultation&#46; The sensitivity and specificity of METSe for detecting patients with &#60;4 MET<span class="elsevierStyleInf">VO2</span> was 3&#46;12&#37; and 100&#37;&#44; respectively&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">The results of this study show that calculating metabolic equivalents in the pre-anaesthesia consultation overestimates the functional capacity of patients scheduled for lung resection surgery when compared with ergometry-based METs&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Measuring functional capacity is a pivotal step in the preoperative evaluation&#44; and in lung resection surgery in particular VO<span class="elsevierStyleInf">2</span>max can determine the extent of the resection&#46; In our sample&#44; 32 of the 104 patients were classed as high risk according to MET<span class="elsevierStyleInf">VO2</span>&#44; but only 1 was correctly classed on the basis of the pre-anaesthesia consultation&#46; This shows that estimating functional capacity on the basis of a questionnaire has a sensitivity of just 3&#46;12&#37; compared to ergometry-based estimations&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Several authors have attempted to describe reliable methods for estimating functional capacity during the pre-anaesthesia evaluation without the need for complex and expensive tests&#46; Most of the tests studied have consisted of questionnaires designed to quantify the patient&#39;s physical status&#44; such as the Duke Activity Status Index &#40;DASI&#41; or similar tools<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46; The problem with these questionnaires is that they rely on the patient&#8217;s or doctor&#8217;s subjective opinion&#44; and studies have found that validated questionnaires tend to overestimate functional capacity<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46; Our results are consistent with those of other authors&#44; such as Wijeysundera et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#44; who found that the anaesthesiologist&#8217;s subjective assessment of patients scheduled for major surgery in the pre-anaesthesia evaluation had 19&#46;2&#37; sensitivity and a 94&#46;7&#37; specificity to detect patients with &#60;4 METs compared with ergometry&#46; Stokes et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#44; meanwhile&#44; compared METSe with estimates obtained using the DASI questionnaire administered during the preoperative evaluation of 204 patients scheduled for major surgery&#44; and found the 53&#46;4&#37; of patients were quantified as &#60;4 METs by the DASI vs&#46; 8&#37; by METSe&#59; however&#44; the authors did not perform cardiopulmonary function tests on any patients in this study&#46; In our sample&#44; METSe correlated adequately with MET<span class="elsevierStyleInf">VO2</span> in only 26 patients &#40;25&#37;&#41; &#40;&#954;&#8239;&#61;&#8239;&#8722;0&#46;107&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Our study has several limitations&#46; First&#44; it is a retrospective chart review&#46; Second&#44; our study population included only patients scheduled for lung resection surgery&#44; and therefore our results cannot be extrapolated to other surgical populations&#46; Finally&#44; given the absence of detailed data regarding postoperative complications&#44; we were unable to analyse whether subjective or objective functional capacity is clinically relevant in predicting surgical and cardiorespiratory complications&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In conclusion&#44; the simplified&#44; subjective method of assessing functional capacity does not correlate with VO<span class="elsevierStyleInf">2</span>max&#44; and therefore should not replace objective testing in patients scheduled for lung resection surgery&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Funding</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have not received funding for this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interests</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare&#46;</p></span></span>"
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    "fechaRecibido" => "2020-11-16"
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            0 => "Thoracic surgery"
            1 => "Thoracic anaesthesia"
            2 => "Pre-anaesthesia"
            3 => "Maximal oxygen consumption"
            4 => "Functional capacity"
            5 => "Ergometry"
            6 => "Metabolic equivalent"
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          "palabras" => array:7 [
            0 => "Cirug&#237;a tor&#225;cica"
            1 => "Anestesia tor&#225;cica"
            2 => "Preanestesia"
            3 => "Consumo m&#225;ximo de ox&#237;geno"
            4 => "Capacidad funcional"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objective</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Metabolic equivalent of task &#40;MET&#41; is a physiological measure that represents the metabolic cost of an activity of daily living&#46; One MET is equivalent to the resting metabolic rate&#46; METs can be estimated by questionnaires or calculated by measuring maximal oxygen uptake &#40;VO2max&#41;&#46; The aim of this study is to determine whether METs estimated in the pre-consultation &#40;METse&#41; correlates with METs calculated from VO2max &#40;METsVO2&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Retrospective observational study in patients scheduled for lung resection surgery&#46; The estimation of METs was obtained in the pre-consultation according to the 2014 European and American guidelines for preoperative cardiovascular assessment in non-cardiac surgery&#46; VO2max was calculated in the ergometry laboratory&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">A total of 104 patients were included in the study&#44; of whom 25 &#40;24&#37;&#41; were female&#46; The mean age was 65&#46;1 years &#40;&#177;9&#46;8&#41;&#46; In 26 patients &#40;25&#37;&#41;&#44; the METse classification correlated with METsVO2 &#40;&#954;&#8239;&#61;&#8239;&#8722;0&#46;107 <span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#46;02&#41;&#46; In the remaining patients&#44; METse overestimated functional capacity measured by ergometry &#40;METse&#8239;&#62;&#8239;METsVO2&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Subjective assessment overestimates functional capacity and should not replace objective testing in patients scheduled for lung resection surgery&#46;</p></span>"
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          0 => array:2 [
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes y objetivo</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Los equivalentes metab&#243;licos &#40;METS&#41; son una medida fisiol&#243;gica que representa el coste metab&#243;lico de una actividad de la vida cotidiana&#46; Un MET equivale al consumo metab&#243;lico en reposo&#46; Los METS se pueden estimar mediante cuestionarios o calcular a partir de la medida del m&#225;ximo consumo de ox&#237;geno &#40;VO<span class="elsevierStyleInf">2</span>max&#41;&#46; El objetivo de este estudio es determinar si existe concordancia entre los METS estimados en la consulta de preanestesia &#40;METSe&#41; con los METS calculados a partir de VO<span class="elsevierStyleInf">2</span>max &#40;METS<span class="elsevierStyleInf">VO2</span>&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional retrospectivo en pacientes candidatos a cirug&#237;a de resecci&#243;n pulmonar&#46; La estimaci&#243;n de los METSe se obtuvo en la consulta de preanestesia de acuerdo a las gu&#237;as europeas y americanas de valoraci&#243;n cardiovascular preoperatoria en cirug&#237;a no cardiaca de 2014&#46; El VO<span class="elsevierStyleInf">2</span>max se calcul&#243; en el laboratorio de ergometr&#237;a&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron un total de 104 pacientes en el estudio&#44; de los que 25 &#40;24&#37;&#41; eran mujeres&#46; La edad media fue de 65&#44;1 a&#241;os &#40;&#177;9&#44;8&#41;&#46; Veintis&#233;is pacientes &#40;25&#37;&#41; presentaron una clasificaci&#243;n concordante de METSe con METS<span class="elsevierStyleInf">VO2</span> &#40;&#954;&#8239;&#61;&#8239;&#8722;0&#44;107 <span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#44;02&#41;&#46; En el resto de los pacientes&#44; los METSe sobreestimaron la capacidad funcional medida por ergometr&#237;a &#40;METSe&#8239;&#62;&#8239;METS <span class="elsevierStyleInf">VO2</span>&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">La valoraci&#243;n subjetiva sobreestima la capacidad funcional y no debe reemplazar la realizaci&#243;n de pruebas objetivas en pacientes propuestos para cirug&#237;a de resecci&#243;n pulmonar&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Nieves-Alonso JM&#44; M&#233;ndez Hern&#225;ndez RM&#44; Ramasco Rueda F&#44; Planas Roca A&#46; Los equivalentes metab&#243;licos estimados no se relacionan con el consumo m&#225;ximo de ox&#237;geno calculado en pacientes candidatos a cirug&#237;a de resecci&#243;n pulmonar&#46; Rev Esp Anestesiol Reanim&#46; 2022&#59;69&#58;437&#8211;441&#46;</p>"
      ]
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      0 => array:8 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
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        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Distribution of the results of the MET evaluation in the pre-anaesthesia consultation and in the stress test laboratory&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">METSe&#58; metabolic equivalents quantified in the pre-anaesthesia consultation&#59; MET<span class="elsevierStyleInf">VO2</span>&#58; metabolic equivalents calculated by ergometry&#46;</p>"
        ]
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      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0010"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Source&#58; the ACC&#47;AHA Perioperative Cardiovascular Evaluation Guidelines for Noncardiac Surgery &#40;Fleisher et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#41; and the second revision of the compendium of physical activities &#40;Ainsworth et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#41;&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Functional capacity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Metabolic equivalents &#40;METs&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Example of activity&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class1 - Excellent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vigorous activity &#40;running&#44; competitive sport&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class II - Good&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#8722;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Climbing stairs with shopping bags&#44; moderate exercise &#40;paddle tennis&#44; basketball&#44; swimming&#44; etc&#46;&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class III - Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#8722;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Climbing one flight of stairs&#44; strenuous home activities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class IV - Poor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unable to climb one flight of stairs&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Functional capacity estimated on the basis of daily physical activities&#44; expressed in metabolic equivalents&#46;</p>"
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">BMI&#58; body mass index&#59; DLCO&#58; diffusing capacity for carbon monoxide&#59; FEV1&#58; forced expiratory volume in1 second&#59; METSe&#58; metabolic equivalents quantified in the pre-anaesthesia consultation&#59; MET<span class="elsevierStyleInf">VO2</span>&#58; metabolic equivalents calculated by ergometry&#59; SD&#58; standard deviation&#59; VO<span class="elsevierStyleInf">2max</span>&#58; maximal oxygen uptake&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Demographic variables</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Age &#40;years&#41;&#59; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Women&#59; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">25 &#40;24&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Men&#59; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">79 &#40;76&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>BMI &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#59; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&#46;8 &#40;5&#46;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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>FEV1&#59; &#37; of predicted &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">79&#46;2 &#40;20&#46;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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>DLCO&#59; &#37; of predicted &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">83&#46;3 &#40;19&#46;3&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>VO<span class="elsevierStyleInf">2max</span>&#59; &#40;mL&#47;kg&#47;min&#41; &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">15&#46;8 &#40;3&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">METSe&#59; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#60;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>4&#8722;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">48 &#40;46&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>7&#8722;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46 &#40;44&#46;2&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9 &#40;8&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">MET<span class="elsevierStyleInf">VO2</span>&#59; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#60;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">32 &#40;30&#46;8&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>4&#8722;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">72 &#40;69&#46;2&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>7&#8722;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;10&nbsp;\t\t\t\t\t\t\n
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    "bibliografia" => array:2 [
      "titulo" => "References"
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Article information

ISSN: 23411929
Original language: English

DOI:10.1016/j.redare.2021.01.006

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