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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">La respuesta metab&#243;lica al estr&#233;s en la enfermedad cr&#237;tica supone&#44; tras una corta fase inicial de depresi&#243;n del metabolismo&#44; con disminuci&#243;n del consumo de ox&#237;geno y del gasto energ&#233;tico&#44; que no suele extenderse m&#225;s all&#225; de las primeras horas&#44; una situaci&#243;n de hipercatabolismo&#44; regulada por una serie de cambios hormonales&#44; con elevaci&#243;n de los niveles de insulina&#44; glucag&#243;n&#44; cortisol&#44; catecolaminas y citoquinas proinflamatorias&#44; que condiciona un aumento del recambio de glucosa y de l&#237;pidos y&#44; de forma m&#225;s caracter&#237;stica&#44; un aumento del <span class="elsevierStyleItalic">turnover</span> o reemplazo proteico<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; Los amino&#225;cidos procedentes del m&#250;sculo esquel&#233;tico son utilizados en el h&#237;gado para la s&#237;ntesis de mediadores inflamatorios y prote&#237;nas estructurales y obtenci&#243;n de energ&#237;a mediante la gluconeog&#233;nesis<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">3</span></a>&#46; As&#237;&#44; tiene lugar un aumento tanto de la s&#237;ntesis como de la degradaci&#243;n proteica&#44; predominando esta &#250;ltima&#44; lo que conduce a un metabolismo proteico netamente negativo<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">2&#44;3</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">La administraci&#243;n de prote&#237;nas ex&#243;genas en la dieta no frena esta respuesta&#46; Sin embargo&#44; la s&#237;ntesis proteica puede verse estimulada mediante un aporte energ&#233;tico y proteico suficiente&#44; de forma que la instauraci&#243;n del soporte nutricional de forma precoz favorece la m&#225;s r&#225;pida adquisici&#243;n de los objetivos nutricionales del paciente&#44; mejorando los resultados cl&#237;nicos en ni&#241;os cr&#237;ticamente enfermos<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">4-8</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">La evidencia en el campo de la nutrici&#243;n en el ni&#241;o cr&#237;tico es limitada&#46; Las recomendaciones internacionales actuales<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">9-11</span></a>&#44; basadas fundamentalmente en opiniones de expertos&#44; extrapolaciones de datos de adultos y un peque&#241;o n&#250;mero de estudios pedi&#225;tricos<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">12&#44;13</span></a>&#44; proponen un aporte m&#237;nimo de 1&#44;5<span class="elsevierStyleHsp" style=""></span>g de prote&#237;nas&#47;kg&#47;d&#237;a para evitar el d&#233;ficit proteico&#44; si bien reconocen que las necesidades podr&#237;an alcanzar los 2&#44;5-3<span class="elsevierStyleHsp" style=""></span>g&#47;kg&#47;d&#237;a en lactantes&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Estudios previos sugieren que la administraci&#243;n de una f&#243;rmula hiperproteica en lactantes favorece la adquisici&#243;n del balance nitrogenado &#40;BN&#41; positivo<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">14-17</span></a>&#44; mejorando los niveles s&#233;ricos de prote&#237;nas&#44; como prote&#237;na ligada al retinol &#40;<span class="elsevierStyleItalic">retinol-binding protein</span> &#91;RBP&#93;&#41; y prealb&#250;mina<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">15&#44;17&#44;18</span></a> y amino&#225;cidos<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">14&#44;19</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">La administraci&#243;n de aportes proteicos superiores a 3<span class="elsevierStyleHsp" style=""></span>g&#47;kg&#47;d&#237;a se ha relacionado con el desarrollo de hiperuremia y acidosis metab&#243;lica como principales efectos secundarios<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">14&#44;17&#44;20</span></a>&#44; sin haberse reportado complicaciones gastrointestinales relevantes<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">15-22</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Adem&#225;s del soporte nutricional&#44; existen otros factores que podr&#237;an modificar el metabolismo proteico en ni&#241;os cr&#237;ticos&#44; como son la alteraci&#243;n de la funci&#243;n hep&#225;tica o renal&#44; la presencia de quemaduras o la administraci&#243;n de ciertos tratamientos&#46; Pese a que en la literatura se encuentran resultados contradictorios<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">23</span></a>&#44; cl&#225;sicamente se ha propuesto que la administraci&#243;n de corticoides&#44; de uso frecuente en cuidados intensivos&#44; podr&#237;a aumentar la excreci&#243;n urinaria de urea&#44; reduciendo as&#237; el BN<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">24&#44;25</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">El objetivo de este estudio fue analizar si un mayor aporte proteico enteral mejora el metabolismo proteico&#44; evaluado mediante el incremento del BN y los niveles de prote&#237;nas s&#233;ricas &#40;prote&#237;nas totales&#44; alb&#250;mina&#44; prealb&#250;mina&#44; transferrina y RBP&#41;&#44; y evaluar su seguridad&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Material y m&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Dise&#241;o del estudio</span><p id="par0040" class="elsevierStylePara elsevierViewall">Se dise&#241;&#243; un estudio prospectivo&#44; con intervenci&#243;n&#44; abierto&#44; aleatorizado y controlado&#44; llevado a cabo en las unidades de cuidados intensivos pedi&#225;tricos &#40;UCIP&#41; de tres hospitales universitarios espa&#241;oles entre diciembre de 2016 y junio de 2019&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Participantes</span><p id="par0045" class="elsevierStylePara elsevierViewall">Se incluyeron lactantes de entre 1 y 24<span class="elsevierStyleHsp" style=""></span>meses de edad ingresados en UCIP que fuesen a recibir nutrici&#243;n enteral &#40;NE&#41; durante al menos 72<span class="elsevierStyleHsp" style=""></span>horas&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Los pacientes con diabetes mellitus u otros errores cong&#233;nitos del metabolismo&#44; que recib&#237;an nutrici&#243;n parenteral o perfusi&#243;n de bicarbonato&#44; con t&#233;cnicas de depuraci&#243;n extrarrenal&#44; o aquellos que recib&#237;an lactancia materna exclusiva u otras f&#243;rmulas especiales&#44; fueron excluidos del estudio&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Se establecieron los siguientes criterios de retirada&#58; desarrollo de hiperproteinemia &#40;prote&#237;nas totales &#62;<span class="elsevierStyleHsp" style=""></span>85<span class="elsevierStyleHsp" style=""></span>g&#47;l&#41; o hiperuremia &#40;urea s&#233;rica &#62;<span class="elsevierStyleHsp" style=""></span>80<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; en ausencia de alteraci&#243;n de la funci&#243;n renal &#40;de acuerdo con los criterios KDIGO&#41;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">26</span></a> o hipercatabolismo &#40;condici&#243;n subyacente junto con BN negativo&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Se llev&#243; a cabo un muestreo por conveniencia&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">El c&#225;lculo del tama&#241;o muestral se llev&#243; a cabo con el programa EPIDAT 3&#46;1&#46; Considerando un nivel de significaci&#243;n del 5&#37;&#44; una potencia del 80&#37; y la detecci&#243;n de una diferencia estandarizada de medias m&#237;nima de 0&#44;9&#44; se estim&#243; un tama&#241;o muestral m&#237;nimo necesario de 30<span class="elsevierStyleHsp" style=""></span>pacientes por grupo &#40;incluida la correcci&#243;n de Bonferroni&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Los pacientes incluidos fueron asignados&#44; por orden de reclutamiento&#44; a cada uno de los tres grupos de dieta establecidos &#40;grupo control y dos grupos experimentales&#41;&#44; utilizando una tabla de aleatorizaci&#243;n restrictiva por bloques generada con el programa EPIDAT 3&#46;1 &#40;Direcci&#243;n Xeral de Sa&#250;de P&#250;blica de la Conseller&#237;a de Sanidade&#44; Xunta de Galicia&#44; en colaboraci&#243;n con la Unidad de An&#225;lisis de Salud y Sistemas de Informaci&#243;n de Salud de la Organizaci&#243;n Panamericana de la Salud&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Intervenci&#243;n</span><p id="par0075" class="elsevierStylePara elsevierViewall">Todos los pacientes recibieron NE exclusiva&#44; a trav&#233;s de sonda nasog&#225;strica o transpil&#243;rica&#44; iniciada en las primeras 24<span class="elsevierStyleHsp" style=""></span>horas de ingreso&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Los pacientes incluidos en el grupo control&#44; denominado &#171;nutrici&#243;n enteral est&#225;ndar&#187; &#40;NEE&#41;&#44; recibieron el aporte nutricional habitual&#44; siendo alimentados con una f&#243;rmula de inicio &#40;Nidina<span class="elsevierStyleHsp" style=""></span>1&#44; Nestl&#233;&#44; Barcelona&#41;&#46; Los dos grupos experimentales recibieron una f&#243;rmula polim&#233;rica &#40;Infatrini&#44; Nutricia&#44; Madrid&#41;&#58; el grupo denominado &#171;nutrici&#243;n enteral hiperproteica&#187; &#40;NEH&#41; recibi&#243; dicha f&#243;rmula&#44; mientras que el grupo denominado &#171;nutrici&#243;n enteral hiperproteica suplementada&#187; &#40;NEHS&#41; recibi&#243; esta misma f&#243;rmula a&#241;adiendo 2&#44;6<span class="elsevierStyleHsp" style=""></span>g de prote&#237;nas por cada 100<span class="elsevierStyleHsp" style=""></span>ml&#44; mediante un m&#243;dulo proteico a base de prote&#237;nas de leche de vaca no hidrolizadas &#40;Resource Protein Instant&#44; Nestl&#233;&#44; Barcelona&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Las botellas fueron preparadas en la propia unidad o en el servicio de nutrici&#243;n y diet&#233;tica del centro hospitalario&#44; dependiendo del centro participante&#44; y su contenido era conocido por el personal y por la familia&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Se administr&#243; NE a d&#233;bito continuo&#44; inici&#225;ndose a un ritmo de 0&#44;5-1<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;h&#44; con incrementos de 0&#44;5-1<span class="elsevierStyleHsp" style=""></span>ml&#47;kg cada 3-4<span class="elsevierStyleHsp" style=""></span>horas en caso de buena tolerancia&#44; hasta alcanzar un aporte cal&#243;rico de 60-65<span class="elsevierStyleHsp" style=""></span>kcal&#47;kg&#47;d&#237;a&#44; o los requerimientos energ&#233;ticos determinados mediante calorimetr&#237;a indirecta &#40;CI&#41;&#44; en caso de ser realizada&#46; El paso de NE a d&#233;bito continuo a bolos&#44; en aquellos pacientes que la mejor&#237;a cl&#237;nica lo permiti&#243;&#44; no fue considerado criterio de exclusi&#243;n&#44; al mantenerse el mismo aporte nutricional diario&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">El estudio finaliz&#243; tras completar 7<span class="elsevierStyleHsp" style=""></span>d&#237;as de NE&#44; o antes en caso de alta de la UCIP o del cumplimiento de alguno de los criterios de retirada anteriormente descritos&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Se realiz&#243; seguimiento de los pacientes durante 7<span class="elsevierStyleHsp" style=""></span>d&#237;as&#46; En los momentos denominados inicial &#40;primeras 24<span class="elsevierStyleHsp" style=""></span>horas&#41; y final &#40;entre los d&#237;as 3 y 5<span class="elsevierStyleHsp" style=""></span>tras el inicio de la NE&#41; se obtuvieron muestras de sangre y de orina&#44; y se realiz&#243; CI &#40;Datex S5 monitor&#44; E-COVX&#44; GE Healthcare&#47;Datex-Ohmeda&#44; Helsinki&#44; Finlandia&#41;&#44; en caso de disponibilidad y en cumplimiento de los requisitos t&#233;cnicos<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">27</span></a>&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Recogida de datos</span><p id="par0100" class="elsevierStylePara elsevierViewall">Se recogieron datos demogr&#225;ficos y antropom&#233;tricos&#58; edad&#44; sexo&#44; peso&#44; longitud y diagn&#243;stico al ingreso&#46; Se calcularon puntuaciones de gravedad y disfunci&#243;n org&#225;nica utilizando las escalas <span class="elsevierStyleItalic">Pediatric Index of Mortality</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">2</span> &#40;PIM2&#41;&#44; <span class="elsevierStyleItalic">Pediatric Risk of Mortality</span> &#40;PRISM&#41; y <span class="elsevierStyleItalic">Pediatric Logistic Organ Dysfunction</span> &#40;PELOD&#41;&#46; Se registraron la presencia de shock&#44; infecci&#243;n&#44; par&#225;metros ventilatorios y constantes vitales&#46; Se analizaron los niveles plasm&#225;ticos de prote&#237;nas&#44; creatinina y urea&#44; y otros par&#225;metros bioqu&#237;micos&#44; como prote&#237;na<span class="elsevierStyleHsp" style=""></span>C reactiva &#40;PCR&#41; y gasometr&#237;a&#44; en los momentos basal y final&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Se registr&#243; el aporte total energ&#233;tico y proteico&#44; as&#237; como otros tratamientos recibidos &#40;relajantes musculares&#44; sedoanalgesia&#44; diur&#233;ticos&#44; corticoides y drogas vasoactivas&#41;&#44; calculando la escala vasoactiva-inotr&#243;pica<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">28</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Se calcul&#243; el BN restando al aporte de nitr&#243;geno las p&#233;rdidas de nitr&#243;geno&#44; incluyendo la v&#237;a urinaria&#44; la fecal y miscel&#225;nea &#40;piel&#44; sudor&#44; tegumentos&#41;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">29</span></a>&#44; seg&#250;n la siguiente f&#243;rmula&#58;</p><p id="par0115" class="elsevierStylePara elsevierViewall">BN &#40;mg&#47;kg&#41; <span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span> aporte de nitr&#243;geno &#40;mg&#47;kg&#41; &#8722; &#40;nitr&#243;geno urinario total &#40;mg&#47;kg&#41; &#43; 75<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41;</p><p id="par0120" class="elsevierStylePara elsevierViewall">siendo 75<span class="elsevierStyleHsp" style=""></span>mg&#47;kg las p&#233;rdidas fecales y miscel&#225;nea<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">30</span></a>&#46; El nitr&#243;geno urinario total &#40;NUT&#41; se estim&#243; como nitr&#243;geno ureico &#40;mg&#47;kg&#41; &#215;<span class="elsevierStyleHsp" style=""></span>1&#44;25&#44; para incluir las p&#233;rdidas de nitr&#243;geno en forma de amonio&#44; creatinina&#44; urato y amino&#225;cidos<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">31</span></a>&#46; Se utiliz&#243; el factor 6&#44;25 para convertir el aporte proteico en aporte de nitr&#243;geno&#44; representando el contenido medio de nitr&#243;geno por gramo de prote&#237;nas&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Se registraron las complicaciones gastrointestinales&#44; as&#237; como cualquier otro evento adverso inesperado&#44; para evaluar la seguridad de la dieta hiperproteica&#46; La necesidad de suspender la NE fue valorada por el m&#233;dico responsable del paciente en cada momento&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Todos los datos fueron recogidos de forma prospectiva desde la historia cl&#237;nica del paciente y registrados en una hoja de recogida dise&#241;ada a tal efecto&#44; posteriormente custodiada por el investigador principal&#44; traslad&#225;ndose dichos datos&#44; anonimizados mediante el n&#250;mero de paciente asignado en el momento de la inclusi&#243;n&#44; a una base dise&#241;ada utilizando el software SPSS &#40;IBM&#44; Armonk&#44; EE&#46;UU&#46;&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">An&#225;lisis estad&#237;stico</span><p id="par0135" class="elsevierStylePara elsevierViewall">La variable de desenlace principal fue la variaci&#243;n de los valores del BN&#44; en mg&#47;kg&#47;d&#237;a a lo largo del estudio &#40;BN final &#8722; BN inicial&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Las variables secundarias fueron la variaci&#243;n entre los momentos basal y final de los niveles de las prote&#237;nas plasm&#225;ticas &#40;prote&#237;nas totales&#44; alb&#250;mina&#44; prealb&#250;mina&#44; transferrina y RBP&#41;&#44; la incidencia por cada 1&#46;000 pacientes&#47;d&#237;a de hiperuremia &#40;urea s&#233;rica superior a 80 mg&#47;dl&#41; o hiperproteinemia &#40;prote&#237;nas totales superiores a 85 g&#47;l&#41;&#44; constituyendo criterio de retirada del estudio&#44; y la incidencia por cada 1&#46;000 pacientes&#47;d&#237;a de complicaciones gastrointestinales &#40;distensi&#243;n abdominal&#44; v&#243;mitos&#44; diarrea y volumen g&#225;strico residual excesivo&#41; y acidosis metab&#243;lica &#40;pH &#60; 7&#44;35 con bicarbonato &#60; 24mmol&#47;l&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Los c&#225;lculos estad&#237;sticos se realizaron con el software libre R &#40;<a href="http://www.r-project.org/">www&#46;r-project&#46;org</a>&#41;&#44; llevando a cabo un an&#225;lisis por asignaci&#243;n a tratamiento&#46; Las variables cuantitativas se describieron mediante media y desviaci&#243;n t&#237;pica o mediana y rango intercuart&#237;lico &#40;RIC&#41;&#46; Las comparaciones entre grupos se llevaron a cabo mediante la prueba t de Student en las variables con distribuci&#243;n normal y la prueba no param&#233;trica Kruskal-Wallis para aquellas que no la siguen&#46; La normalidad de las distribuciones fue valorada mediante la prueba de Kolmogorov-Smirnov&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Las variables cualitativas se representaron mediante sus frecuencias absolutas y relativas&#44; y las comparaciones entre grupos se realizaron utilizando la prueba chi cuadrado &#40;&#967;<span class="elsevierStyleSup">2</span>&#41;&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">La variaci&#243;n en las variables entre los momentos inicial y final se analiz&#243; utilizando la prueba t de Student para muestras relacionadas&#46; Se utilizaron modelos de regresi&#243;n de efectos mixtos para evaluar la variaci&#243;n de estas variables ajustada por el aporte energ&#233;tico recibido&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">La incidencia de los efectos adversos m&#225;s relevantes se expres&#243; mediante intervalos de confianza &#40;IC&#41; al 95&#37;&#46; Las comparaciones entre grupos se llevaron a cabo utilizando t&#233;cnicas <span class="elsevierStyleItalic">bootstrap</span>&#46; Se consideraron significativos los valores de p&#60; 0&#44;05&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Consideraciones &#233;ticas</span><p id="par0165" class="elsevierStylePara elsevierViewall">El estudio fue aprobado por los respectivos comit&#233;s de &#233;tica de la investigaci&#243;n y registrado en ClinicalTrials&#46;gov &#40;NCT03901742&#41;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">32</span></a>&#46; Se obtuvo el consentimiento informado por parte de los padres o tutores legales de los pacientes&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Resultados</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Caracter&#237;sticas demogr&#225;ficas</span><p id="par0170" class="elsevierStylePara elsevierViewall">Se incluyeron 112 pacientes entre diciembre de 2016 y junio de 2019&#44; de los que 99 concluyeron el estudio&#44; distribuidos de forma uniforme en cada grupo de dieta &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#44; con edades entre 1 y 24 meses &#40;mediana 4 meses&#41;&#44; siendo el 36&#44;4&#37; mujeres&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">La muestra total mostraba unas puntuaciones medianas de gravedad al ingreso de 2&#44;3 para la escala PRISM&#44; de 1&#44;0 para PIM2 y de 0&#44;1 para PELOD&#44; con una estancia mediana de 6 d&#237;as y una mortalidad del 1&#37;&#46; M&#225;s de la mitad de los pacientes presentaban infecci&#243;n&#44; mientras que solo el 5&#44;1&#37; se encontraban en situaci&#243;n de shock&#46; El 42&#44;3&#37; precisaron ventilaci&#243;n mec&#225;nica invasiva al ingreso&#46; El 35&#44;4&#37; recibieron soporte inotr&#243;pico&#44; con una puntuaci&#243;n mediana de puntuaci&#243;n vasoactiva-inotr&#243;pica de 0&#46; Se administraron relajantes musculares en el 9&#44;2&#37; de los pacientes&#44; y corticoides en el 8&#44;1&#37; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; El 60&#37; de los pacientes ingresaron por insuficiencia respiratoria&#44; el 28&#44;3&#37; tras cirug&#237;a cardiaca&#44; y el 11&#44;1&#37; restante&#44; por otros diagn&#243;sticos&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">No se encontraron diferencias significativas en ninguna variable cl&#237;nica o antropom&#233;trica&#44; ni en los tratamientos recibidos&#44; a excepci&#243;n de los corticoides&#44; que fueron administrados a una mayor proporci&#243;n de pacientes incluidos en el grupo NEHS &#40;p &#61; 0&#44;047&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Aportes nutricionales y gasto energ&#233;tico</span><p id="par0185" class="elsevierStylePara elsevierViewall">El aporte energ&#233;tico medio administrado en el momento final del estudio fue de 74&#44;2 &#40;25&#44;3&#41; kcal&#47;kg&#47;d&#237;a&#44; siendo superior en los pacientes del grupo 2 &#40;p&#61;0&#44;041&#41;&#46; El aporte proteico medio final fue de 2&#44;4 &#40;1&#44;1&#41; g&#47;kg&#47;d&#237;a&#44; obteni&#233;ndose un mayor aporte proteico a mayor contenido proteico de la f&#243;rmula suministrada &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0190" class="elsevierStylePara elsevierViewall">Se realiz&#243; CI en 16 de los 99 pacientes&#44; con un valor medio de 45&#44;2 &#40;8&#44;9&#41; kcal&#47;kg&#47;d&#237;a en el momento inicial y de 50&#44;8 &#40;13&#44;4&#41; kcal&#47;kg&#47;d&#237;a en el final&#46; No se encontr&#243; variaci&#243;n significativa del gasto energ&#233;tico en reposo &#40;GER&#41; a lo largo del estudio en ninguno de los tres grupos &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46; Tampoco fueron significativas las diferencias entre los tres grupos en el momento basal &#40;p &#61; 0&#44;919&#41; ni en el final &#40;p &#61; 0&#44;315&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Excreci&#243;n urinaria de nitr&#243;geno y variaci&#243;n del BN</span><p id="par0195" class="elsevierStylePara elsevierViewall">Se obtuvieron muestras de orina en 87 &#40;87&#44;9&#37;&#41; pacientes&#59; en 36 de ellos &#40;41&#44;4&#37;&#41;&#44; mediante recogida de orina de 24 horas&#46; En los restantes se analiz&#243; una muestra aislada obtenida a trav&#233;s de colector perineal&#44; calcul&#225;ndose la excreci&#243;n urinaria de nitr&#243;geno diaria mediante una extrapolaci&#243;n de los datos&#44; conocida su diuresis total&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">El NUT en el momento final fue superior en el grupo NEHS &#40;466&#44;4 &#91;232&#44;6&#93; mg&#47;kg&#41; respecto a los grupos NEE &#40;172&#44;2 &#91;180&#44;3&#93; mg&#47;kg&#41; y NEH &#40;213&#44;2 &#91;169&#93; mg&#47;kg&#41; &#40;p&#60; 0&#44;001&#41;&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">El BN fue negativo en el 72&#44;4&#37; de los pacientes en el momento inicial&#44; permaneciendo negativo en el 38&#44;2&#37; en el momento final&#46; Como se observa en la <a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#44; los pacientes de los grupos NEE y NEH presentaron un incremento significativo del BN de 150 &#40;274&#41; mg de nitr&#243;geno&#47;kg&#47;d&#237;a y 149 &#40;201&#41; mg&#47;kg&#47;d&#237;a&#44; respectivamente&#44; mientras que la variaci&#243;n en el grupo NEHS &#40;96 &#91;384&#93; mg&#47;kg&#47;d&#237;a&#41; no fue significativa &#40;p &#61;<span class="elsevierStyleHsp" style=""></span>0&#44;212&#41;&#46; Se obtuvieron valores similares de p tras realizar ajuste por el aporte energ&#233;tico recibido&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Variaci&#243;n en los valores de prote&#237;nas s&#233;ricas</span><p id="par0210" class="elsevierStylePara elsevierViewall">Al analizar el total de la muestra se observ&#243; una mejor&#237;a en los valores de todas las prote&#237;nas estudiadas&#44; excepto la alb&#250;mina&#46; Al estudiar esta variaci&#243;n en los diferentes grupos&#44; el incremento de prote&#237;nas totales fue significativo &#250;nicamente en el grupo NEH&#46; En los grupos NEH y NEHS se observ&#243; un aumento de los niveles de prealb&#250;mina &#40;3&#44;2 &#91;5&#44;0&#93; y 5&#44;6 &#91;7&#44;3&#93; mg&#47;l&#44; respectivamente&#41; y RBP &#40;1&#44;3 &#91;1&#44;4&#93; y 3&#44;0 &#91;1&#44;3&#93; mg&#47;dl&#44; respectivamente&#41;&#44; siendo superior en el grupo con mayor aporte proteico&#46; Los niveles de transferrina aumentaron solo en el grupo NEHS &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Influencia del tratamiento con corticoides sobre la variaci&#243;n de BN y prote&#237;nas s&#233;ricas</span><p id="par0215" class="elsevierStylePara elsevierViewall">Una mayor proporci&#243;n de pacientes del grupo NEHS recibi&#243; tratamiento con corticoides &#40;metilprednisolona 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#237;a o dexametasona 0&#44;6<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#237;a&#41;&#44; por lo que se llev&#243; a cabo un modelo de regresi&#243;n de efectos mixtos para evaluar su influencia sobre el metabolismo proteico&#46; No se encontraron efectos significativos sobre la variaci&#243;n del BN &#40;p &#61; 0&#44;227&#41;&#44; prote&#237;nas totales &#40;p &#61; 0&#44;348&#41;&#44; alb&#250;mina &#40;p &#61; 0&#44;953&#41;&#44; prealb&#250;mina &#40;p &#61; 0&#44;133&#41;&#44; RBP &#40;p &#61; 0&#44;490&#41; ni transferrina &#40;p &#61; 0&#44;847&#41;&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Seguridad de la dieta hiperproteica e hiperproteica suplementada</span><p id="par0220" class="elsevierStylePara elsevierViewall">El estudio fue finalizado prematuramente en 15 pacientes&#58; 8 desarrollaron hiperuremia &#40;un &#250;nico paciente en el grupo NEH y 7 en el NEHS&#41;&#44; un paciente del grupo NEH present&#243; diarrea y otro en el grupo NEHS sufri&#243; una obstrucci&#243;n de la sonda&#46; Cuatro ni&#241;os con quilot&#243;rax requirieron una formula espec&#237;fica&#44; y un paciente en shock precis&#243; restricci&#243;n h&#237;drica&#44; impidiendo continuar con la NE&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Los niveles de urea s&#233;rica fueron superiores a mayor aporte proteico recibido &#40;p &#60; 0&#44;001&#41;&#44; con una mayor incidencia de hiperuremia en los pacientes incluidos en el grupo NEHS&#44; seguido de los del grupo NEH &#40;p &#61; 0&#44;003&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">tabla 6</a>&#41;&#46; No se detectaron casos de hiperproteinemia ni de acidosis metab&#243;lica&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0230" class="elsevierStylePara elsevierViewall">No se encontraron diferencias entre grupos en cuanto a tolerancia gastrointestinal &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">tabla 6</a>&#41;&#46;</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Discusi&#243;n</span><p id="par0235" class="elsevierStylePara elsevierViewall">Nuestro estudio evalu&#243; el efecto del aporte enteral de tres niveles diferentes de prote&#237;nas sobre el BN&#44; sustituto del balance proteico&#44; y las prote&#237;nas s&#233;ricas en lactantes cr&#237;ticamente enfermos&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">La adecuaci&#243;n del aporte a la prescripci&#243;n de prote&#237;nas en ni&#241;os cr&#237;ticamente enfermos se ha relacionado con una menor morbimortalidad<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">5</span></a> y duraci&#243;n de la ventilaci&#243;n mec&#225;nica<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">6-8</span></a>&#46; Sin embargo&#44; el aporte proteico &#243;ptimo no ha sido establecido a&#250;n&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">El reemplazo proteico es un proceso energ&#233;ticamente costoso<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">3</span></a>&#44; de forma que la s&#237;ntesis proteica depende no solo del aporte proteico&#44; sino tambi&#233;n de un adecuado aporte energ&#233;tico&#46; Estudios previos han sugerido un umbral m&#237;nimo de 57<span class="elsevierStyleHsp" style=""></span>kcal&#47;kg&#47;d&#237;a y 1&#44;5<span class="elsevierStyleHsp" style=""></span>g de prote&#237;nas&#47;kg&#47;d&#237;a para alcanzar un balance proteico positivo<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">12&#44;13</span></a>&#46; Nuestros pacientes recibieron una media de 74&#44;2<span class="elsevierStyleHsp" style=""></span>kcal&#47;kg&#47;d&#237;a&#44; superior a su GER medio medido mediante CI&#44; lo cual deber&#237;a ser suficiente para no limitar la s&#237;ntesis proteica&#44; y un aporte proteico superior a 1&#44;5<span class="elsevierStyleHsp" style=""></span>g&#47;kg&#47;d&#237;a&#44; superando la cifra sugerida por las principales gu&#237;as internacionales en cuidados intensivos pedi&#225;tricos<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">9</span></a>&#46; Sin embargo&#44; los pacientes incluidos en el grupo NEHS recibieron 3&#44;4<span class="elsevierStyleHsp" style=""></span>g de prote&#237;nas&#47;kg&#47;d&#237;a&#44; una cantidad ligeramente superior a la recomendada para lactantes<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">14-16&#44;19</span></a>&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Tras 3-5 d&#237;as de NE tuvo lugar una mejor&#237;a en el BN en el total de la muestra&#46; De hecho&#44; el BN se positiviz&#243; en el 27&#44;3&#37; de los pacientes&#44; lo que apoya la hip&#243;tesis de que establecer una NE precoz es fundamental para evitar favorecer el catabolismo y el mantenimiento de un balance proteico negativo en pacientes cr&#237;ticos&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Al estudiar la variaci&#243;n del BN en funci&#243;n de la dieta se observ&#243; un aumento similar en los grupos NEE y NEH&#46; Sin embargo&#44; pese a que los ni&#241;os alimentados con NEHS recibieron un mayor aporte proteico&#44; el aumento del BN fue menor&#44; sin alcanzar la significaci&#243;n estad&#237;stica&#46; Una alta proporci&#243;n de los pacientes de este grupo fueron tratados con corticoides &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; El uso de corticoides se ha relacionado cl&#225;sicamente con una disminuci&#243;n del BN al aumentar la excreci&#243;n urinaria de urea<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">24&#44;25</span></a>&#46; Sin embargo&#44; no hemos encontrado una influencia significativa de los corticoides sobre el metabolismo proteico en nuestra muestra&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Varios ensayos cl&#237;nicos que analizaron el efecto de la dieta hiperproteica encontraron una asociaci&#243;n entre un mayor aporte proteico&#44; una m&#225;s r&#225;pida adquisici&#243;n de los objetivos nutricionales y la mejor&#237;a en el BN en ni&#241;os cr&#237;ticamente enfermos con aporte proteico en torno a 2&#44;7<span class="elsevierStyleHsp" style=""></span>g&#47;kg&#47;d&#237;a respecto a 1&#44;5<span class="elsevierStyleHsp" style=""></span>g&#47;kg&#47;d&#237;a<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">14-16</span></a>&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">En nuestro estudio&#44; los pacientes que recibieron NEH y NEHS presentaron un aumento de prealb&#250;mina y de RBP&#44; siendo este incremento mayor a mayor aporte proteico recibido&#46; Tanto la RBP como la prealb&#250;mina son prote&#237;nas de vida media corta&#44; con un bajo volumen de distribuci&#243;n&#44; considerados marcadores nutricionales precoces y sensibles<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">33</span></a>&#46; Incrementos significativos de estas prote&#237;nas han sido previamente reportados en ni&#241;os cr&#237;ticos alimentados con f&#243;rmula hiperproteica<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">15&#44;18</span></a>&#46; No obstante&#44; estas variaciones deben ser interpretadas con cautela&#44; puesto que su s&#237;ntesis hep&#225;tica puede verse influida negativamente en favor de la s&#237;ntesis de reactantes de fase aguda en estados de inflamaci&#243;n<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">33</span></a>&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">La suplementaci&#243;n proteica implica un aumento de la osmolaridad de la f&#243;rmula que podr&#237;a interferir en la tolerancia digestiva<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">34</span></a>&#46; De acuerdo con estudios previos<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">14&#44;15&#44;34</span></a>&#44; en los que se reportaron casos infrecuentes y tolerables de diarrea&#44; distensi&#243;n abdominal y aumento del volumen g&#225;strico residual como principales efectos secundarios gastrointestinales<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">16&#44;18</span></a>&#44; no hemos encontrado complicaciones digestivas relevantes en los pacientes que recibieron dieta hiperproteica&#46; Sin embargo&#44; tuvo lugar una obstrucci&#243;n de la sonda nasog&#225;strica en un lactante con NEHS&#44; atribuible a una densidad excesiva del preparado&#44; poniendo de manifiesto la importancia no solo de la osmolaridad&#44; sino tambi&#233;n de las caracter&#237;sticas f&#237;sicas de la f&#243;rmula a administrar&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">Un aporte proteico excesivo conduce a la oxidaci&#243;n del excedente de prote&#237;nas&#44; favoreciendo la elevaci&#243;n de los niveles plasm&#225;ticos de urea&#46; De acuerdo con la literatura<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">14&#44;20</span></a>&#44; los pacientes que recibieron NEHS presentaron niveles superiores de urea&#44; con una mayor incidencia de hiperuremia &#40;urea &#62; 80<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&#46; Esto sugiere que mientras que el aporte enteral de unos 2&#44;2<span class="elsevierStyleHsp" style=""></span>g&#47;kg&#47;d&#237;a de prote&#237;nas favorece el metabolismo proteico en lactantes cr&#237;ticamente enfermos sin efectos secundarios relevantes&#44; un aporte de 3&#44;4<span class="elsevierStyleHsp" style=""></span>g&#47;kg&#47;d&#237;a podr&#237;a ser excesivo en este tipo de pacientes&#46;</p><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Limitaciones</span><p id="par0280" class="elsevierStylePara elsevierViewall">Nuestro estudio cuenta con una serie de limitaciones metodol&#243;gicas&#46; En primer lugar&#44; una gran proporci&#243;n de pacientes no portaba sonda urinaria&#44; por lo que una parte sustancial de la recogida de orina se llev&#243; a cabo por micci&#243;n aislada&#46; Aunque algunos estudios han mostrado una correlaci&#243;n aceptable entre la determinaci&#243;n de NUT en orina de 24 horas y periodos de recogida menores<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">35&#44;36</span></a>&#44; se ha demostrado una gran variabilidad en la excreci&#243;n urinaria de urea en ni&#241;os cr&#237;ticos&#44; encontr&#225;ndose en la literatura valores de NUT entre 100 y 1&#46;000<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#237;a<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">14&#44;37-39</span></a>&#46; Este dato compromete la fiabilidad de su determinaci&#243;n en periodos cortos de tiempo<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">40</span></a>&#44; y por tanto la validez de nuestros resultados respecto al BN&#46; Sin embargo&#44; son muchos los ni&#241;os cr&#237;ticamente enfermos sin sonda vesical&#44; lo que hace que nuestros resultados puedan ser &#250;tiles en la pr&#225;ctica cl&#237;nica&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">Adem&#225;s&#44; los pacientes de los tres grupos deber&#237;an haber recibido un mismo aporte energ&#233;tico para poder asegurar que la variaci&#243;n del metabolismo proteico sea atribuible &#250;nicamente a las diferencias en el aporte proteico&#46; Sin embargo&#44; hemos preferido utilizar f&#243;rmulas comerciales&#44; en lugar de confeccionarlas especialmente para el estudio&#44; lo que habr&#237;a permitido igualar el aporte energ&#233;tico entre grupos&#44; para reproducir m&#225;s fielmente lo que sucede realmente en la pr&#225;ctica cl&#237;nica&#46; No obstante&#44; tras el ajuste por aporte cal&#243;rico&#44; tampoco hemos encontrado cambios relevantes en nuestros resultados en cuanto a la variaci&#243;n de la BN y las prote&#237;nas s&#233;ricas&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Fortalezas</span><p id="par0290" class="elsevierStylePara elsevierViewall">Nuestro estudio propone un ensayo cl&#237;nico llevado a cabo con pacientes en la pr&#225;ctica cl&#237;nica real&#44; tratando de hacer sus conclusiones aplicables a las condiciones de trabajo asistencial de las UCIP&#46;</p></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Conclusiones</span><p id="par0295" class="elsevierStylePara elsevierViewall">La administraci&#243;n de grandes cantidades de prote&#237;nas mejora el metabolismo proteico&#44; evaluado mediante la variaci&#243;n del BN y de las prote&#237;nas s&#233;ricas&#44; en lactantes cr&#237;ticamente enfermos&#46; El aporte de 2&#44;2<span class="elsevierStyleHsp" style=""></span>g de prote&#237;nas&#47;kg&#47;d&#237;a&#44; cantidad superior al umbral m&#237;nimo recomendado por las principales gu&#237;as internacionales y al habitualmente administrado en el paciente cr&#237;tico pedi&#225;trico&#44; es generalmente seguro y bien tolerado&#44; mientras que aportes en torno a 3&#44;4<span class="elsevierStyleHsp" style=""></span>g&#47;kg&#47;d&#237;a pueden producir hiperuremia en algunos pacientes&#46; Son necesarios nuevos estudios para establecer el aporte proteico &#243;ptimo&#44; probablemente situado entre estas dos cifras&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Financiaci&#243;n</span><p id="par0300" class="elsevierStylePara elsevierViewall">El estudio ha sido financiado con el apoyo del Instituto de Investigaci&#243;n Carlos<span class="elsevierStyleHsp" style=""></span>III y del Fondo Europeo de Desarrollo Regional &#40;ERDF&#41; ref&#46; PI11&#47;00721&#44; y la Red SAMID&#44; RETICS&#44; fundada por el Plan Nacional I&#43;D&#43;I 2008-2011&#46; ISCIII &#8211; Subdirecci&#243;n General de Evaluaci&#243;n y Fomento de la Investigaci&#243;n y el Fondo Europeo de Desarrollo Regional &#40;ERDF&#41; ref&#46; RD16&#47;0022&#47;0007&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Autor&#237;a</span><p id="par0305" class="elsevierStylePara elsevierViewall">A&#46; Carrillo&#44; C&#46; Rey y J&#46; L&#243;pez-Herce han contribuido igualmente en la concepci&#243;n y el dise&#241;o del estudio&#46; J&#46; Urbano ha contribuido al dise&#241;o del estudio&#59; R&#46; Fern&#225;ndez&#44; J&#46; Urbano&#44; A&#46; Vivanco y M&#46;J&#46; Solana han contribuido en la implementaci&#243;n del estudio en los centros participantes&#44; en la inclusi&#243;n activa de pacientes y en la adquisici&#243;n de datos&#46; S&#46; D&#237;az ha contribuido al an&#225;lisis de los datos&#46; Todos los autores han participado en la redacci&#243;n del texto y sus revisiones&#44; aprobando el manuscrito enviado para su consideraci&#243;n&#46;</p></span></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introducci&#243;n</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">No se ha establecido cu&#225;l es el aporte &#243;ptimo para mejorar el metabolismo proteico sin producir efectos adversos en lactantes gravemente enfermos&#46; Nuestro objetivo fue analizar si un mayor aporte proteico a trav&#233;s de la nutrici&#243;n enteral se relaciona con una mejor&#237;a en el balance proteico en lactantes cr&#237;ticamente enfermos&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Material y m&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se dise&#241;&#243; un estudio multic&#233;ntrico&#44; prospectivo&#44; aleatorizado y controlado &#40;diciembre de 2016 a junio de 2019&#41;&#46; Se incluyeron lactantes cr&#237;ticamente enfermos con nutrici&#243;n enteral&#44; asign&#225;ndose aleatoriamente a tres dietas con diferente contenido proteico&#58; est&#225;ndar &#40;1&#44;7<span class="elsevierStyleHsp" style=""></span>g&#47;100<span class="elsevierStyleHsp" style=""></span>ml&#41;&#44; hiperproteica &#40;2&#44;7<span class="elsevierStyleHsp" style=""></span>g&#47;100<span class="elsevierStyleHsp" style=""></span>ml&#41; e hiperproteica suplementada &#40;5&#44;1<span class="elsevierStyleHsp" style=""></span>g&#47;100<span class="elsevierStyleHsp" style=""></span>ml&#41;&#46; Se realizaron an&#225;lisis de sangre y orina y se calcul&#243; el balance nitrogenado en el momento basal y tras 3-5<span class="elsevierStyleHsp" style=""></span>d&#237;as de nutrici&#243;n&#46; Se analiz&#243; la variaci&#243;n del balance nitrogenado y de las prote&#237;nas s&#233;ricas &#40;prote&#237;nas totales&#44; alb&#250;mina&#44; transferrina&#44; prealb&#250;mina y prote&#237;na ligada al retinol&#41; a lo largo del periodo de estudio&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Noventa y nueve lactantes &#40;33 por grupo&#41; completaron el estudio&#46; No se encontraron diferencias entre grupos en caracter&#237;sticas demogr&#225;ficas&#44; puntuaciones de gravedad y otros tratamientos recibidos&#44; salvo corticoides&#44; administrados en una mayor proporci&#243;n de pacientes del tercer grupo&#46; Tuvo lugar un aumento significativo de los niveles de prealb&#250;mina y prote&#237;na ligada al retinol en los grupos con nutrici&#243;n hiperproteica e hiperproteica suplementada&#46; El balance nitrogenado aument&#243; en todos los grupos&#44; pero este incremento no fue significativo en el grupo de nutrici&#243;n hiperproteica suplementada&#46; No se encontraron diferencias en cuanto a tolerancia gastrointestinal&#46; Los pacientes con nutrici&#243;n hiperproteica suplementada presentaron niveles superiores de urea s&#233;rica y mayor incidencia de hiperuremia&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusiones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La administraci&#243;n enteral de altas cantidades de prote&#237;nas mejora los niveles de prote&#237;nas s&#233;ricas en lactantes cr&#237;ticamente enfermos&#46; Un aporte proteico de 2&#44;2<span class="elsevierStyleHsp" style=""></span>g&#47;kg&#47;d&#237;a es generalmente seguro y bien tolerado&#44; mientras que aportes de 3&#44;4<span class="elsevierStyleHsp" style=""></span>g&#47;kg&#47;d&#237;a pueden producir hiperuremia en algunos pacientes&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Introducci&#243;n"
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          1 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Material y m&#233;todos"
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            "titulo" => "Resultados"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introduction</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The optimal intake to improve protein metabolism without producing adverse effects in seriously ill infants has yet to be established&#46; The aim of our study was to analyse whether an increased protein intake delivered through enteral nutrition would be associated with an improvement in nitrogen balance and serum protein levels in critically ill infants&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Material and methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">We conducted a multicentre&#44; prospective randomized controlled trial &#40;December 2016-June 2019&#41;&#46; The sample consisted of critically ill infants receiving enteral nutrition assigned randomly to 3 protein content groups&#58; standard diet &#40;1&#46;7<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#41;&#44; protein-enriched diet &#40;2&#46;7<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#41; and high protein-enriched diet &#40;5&#46;1<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#41;&#46; Blood and urine tests were performed&#44; and we assessed nitrogen balance at baseline and at 3 to 5<span class="elsevierStyleHsp" style=""></span>days of the diet&#46; We analysed variations in nitrogen balance and serum protein levels &#40;total protein&#44; albumin&#44; transferrin&#44; prealbumin&#44; and retinol-binding protein&#41; throughout the study period&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Ninety-nine infants &#40;33 per group&#41; completed the study&#46; We did not find any differences were between groups in demographic characteristics&#44; severity scores or prescribed medications&#44; except for corticosteroids&#44; administered in a higher proportion of patients in the third group&#46; We observed significant increases in prealbumin and retinol-binding protein levels in patients receiving the protein-enriched and high protein-enriched diets at 3 to 5<span class="elsevierStyleHsp" style=""></span>days compared to baseline&#46; The nitrogen balance increased in all groups&#44; but the differences were not significant in the high protein-enriched group&#46; There were no differences in gastrointestinal tolerance&#46; Patients fed high protein-enriched formula had higher levels of serum urea&#44; with a higher incidence of hyperuraemia in this group&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusion</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Enteral administration of higher amounts of protein improves serum protein levels in critically ill children&#46; A protein intake of 2&#46;2<span class="elsevierStyleHsp" style=""></span>g&#47;kg&#47;day is generally safe and well tolerated&#44; whereas an intake of 3&#46;4<span class="elsevierStyleHsp" style=""></span>g&#47;kg&#47;day may produce hyperuraemia in some patients&#46;</p></span>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>99&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Dieta est&#225;ndar&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>33&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Dieta hiperproteica&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>33&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Dieta hiperproteica suplementada&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>33&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Edad&#44; meses<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;4&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;4&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;5&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;5&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;189&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sexo femenino&#44; 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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36 &#40;36&#44;4&#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">8 &#40;24&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;42&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;42&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;265&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\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#44;9 &#40;2&#44;2&#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</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#44;8 &#40;2&#44;3&#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">6&#44;4 &#40;2&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;179&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</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&#44;6 &#40;8&#44;3&#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">58&#44;7 &#40;5&#44;8&#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">60&#44;9 &#40;9&#44;1&#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">62&#44;1 &#40;9&#44;3&#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">0&#44;461&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;3 &#40;3&#44;9&#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">2&#44;3 &#40;3&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;8 &#40;4&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;2 &#40;4&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;867&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</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;0 &#40;2&#44;4&#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">0&#44;8 &#40;1&#44;8&#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
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                  \t\t\t\t">1&#44;8 &#40;3&#44;2&#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">0&#44;9 &#40;1&#44;7&#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">0&#44;259&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">PELOD&#44; &#37;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0 &#40;0&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">66&#44;7&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">50&#44;0&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">63&#44;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#44;342&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#44;1&#37;&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
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">42&#44;3&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">51&#44;6&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">42&#44;4&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;344&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</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 &#40;12&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;12&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;16&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;10&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;342&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">Relajantes musculares&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#44;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#44;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#44;1&#37;&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">12&#44;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;906&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">Corticoides&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#44;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#44;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;047&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">Duraci&#243;n del ingreso en UCIP&#44; d&#237;as<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#44;0 &#40;7&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#44;0 &#40;8&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#44;0 &#40;6&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#44;5 &#40;7&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;658&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">Mortalidad&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Valores expresados como mediana &#40;rango intercuart&#237;lico&#41;&#46;</p>"
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            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Valores expresados como media &#40;desviaci&#243;n t&#237;pica&#41;&#46;</p>"
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        "descripcion" => array:1 [
          "es" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Comparaci&#243;n de las caracter&#237;sticas basales y principales resultados en los tres grupos de estudio</p>"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Valores expresados como media &#40;desviaci&#243;n t&#237;pica&#41;&#46;</p>"
          "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">F&#243;rmula nutricional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>99&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Dieta est&#225;ndar&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>33&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Dieta hiperproteica&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>33&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Dieta hiperproteica suplementada&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>33&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aporte energ&#233;tico &#40;kcal&#47;kg&#47;d&#237;a&#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">74&#44;2 &#40;25&#44;3&#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">67&#44;1 &#40;21&#44;3&#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">84&#44;3 &#40;31&#44;5&#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">71&#44;2 &#40;18&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;041&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">Aporte proteico &#40;g&#47;kg&#47;d&#237;a&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;4 &#40;1&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;7 &#40;0&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;2 &#40;0&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;4 &#40;1&#44;2&#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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        "descripcion" => array:1 [
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          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">GER&#58; gasto energ&#233;tico en reposo&#46;</p><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Valores expresados como media &#40;desviaci&#243;n t&#237;pica&#41;&#46;</p>"
          "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">GER &#40;kcal&#47;kg&#47;d&#237;a&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>16&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Dieta est&#225;ndar&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Dieta hiperproteica&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Dieta hiperproteica suplementada&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inicial&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">45&#44;2 &#40;8&#44;9&#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">44&#44;2 &#40;11&#44;2&#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">46&#44;1 &#40;7&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>p ajustado<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Alb&#250;mina &#40;g&#47;l&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Inicial&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Final&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Variaci&#243;n&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  " align="left" valign="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Inicial&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\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>Final&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">13&#44;7 &#40;6&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Variaci&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>p ajustado<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Final&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Variaci&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\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\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="elsevierStyleItalic">Transferrina &#40;g&#47;l&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \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>Inicial&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\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">174&#44;7 &#40;63&#44;4&#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>Final&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">193&#44;4 &#40;54&#44;6&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">186&#44;7 &#40;45&#44;6&#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">194&#44;8 &#40;59&#44;9&#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">197&#44;3 &#40;57&#44;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
                  \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>Variaci&#243;n&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
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                  \t\t\t\t  " align="left" valign="\n
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                  \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="elsevierStyleItalic">Distensi&#243;n abdominal</span><a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;466&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
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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