Original article
Health-related quality of life in patients with bronchiolitis obliterans
Qualidade de vida relacionada à saúde em pacientes com bronquiolite obliterante
Edgar E. Sarriaa, Eduardo Mundstockb,c, Denise G. Machadob,d, Helena T. Moceline,f, Gilberto B. Fischerf,g, Silvana P. Furlanh, Ivan C.F. Antonelloi, Ricardo Steinj, Rita Mattiellob,k,
Corresponding author
a Universidade de Santa Cruz do Sul (UNISC), Departamento de Biologia e Farmácia, Santa Cruz do Sul, RS, Brazil
b Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Programa de Pós-Graduação em Pediatria e Saúde da Criança, Porto Alegre, RS, Brazil
c Prefeitura de Canela, Canela, RS, Brazil
d Centro Universitário Ritter dos Reis (UniRitter), Porto Alegre, RS, Brazil
e Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Departamento de Pediatria, Porto Alegre, RS, Brazil
f Hospital da Criança Santo Antônio, Serviço de Pneumologia Pediátrica, Porto Alegre, RS, Brazil
g Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Programa de Pós-Graduação em Pediatria, Porto Alegre, RS, Brazil
h Universidade Federal do Rio Grande do Sul (UFRGS), Programa de Pós Graduação em Saúde da Criança e do Adolescente, Porto Alegre, RS, Brazil
i Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Programa de Pós-Graduação em Medicina, Porto Alegre, RS, Brazil
j Universidade Federal do Rio Grande do Sul (UFRGS), Programa de Pós-Graduação em Cardiologia e Ciências Cardiovasculares, Porto Alegre, RS, Brazil
k Universidade Federal do Rio Grande do Sul (UFRGS), Programa de Pós-Graduação em Epidemiologia, Porto Alegre, RS, Brazil
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Moreover, the use of a subjective and multidimensional tool in clinical practice allows the consideration that changes in health can lead to changes in well-being in the physical, psychological, and social aspects of the patient's life, and <span class="elsevierStyleItalic">vice versa.</span> Factors that are specific to the individuals and that interact with them can modify the health status. Among these, the health-related quality of life (HRQoL) assessment has been recognized as an important method for evaluating patients’ physical and psychosocial health.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">6</span></a> Studies investigating HRQoL in children with asthma, otitis, and cystic fibrosis suggested that children with chronic diseases have lower HRQoL scores than healthy controls, and that specific interventions can improve this outcome.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A significant number of guidelines for patients with chronic pulmonary disease recommend the use of tools that assess HRQoL in clinical practice.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">9</span></a> HRQoL assessment has also been highly appreciated as a clinical outcome in studies that evaluate the effectiveness of interventions; from health planning to studies that monitor the health of populations.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Although in recent years there has been an improvement in the diagnostic and therapeutic techniques of PIBO patients, more multidimensional and subjective methods that can describe the consequences of the disease and the treatment in the different domains considered are still necessary. Based on this perspective, the present study aimed to evaluate the HRQoL of patients with a diagnosis of PIBO.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">The writing of the article followed the STROBE guidelines.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">10</span></a></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study design</span><p id="par0030" class="elsevierStylePara elsevierViewall">This was a cross-sectional study.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Context</span><p id="par0035" class="elsevierStylePara elsevierViewall">The research is part of an umbrella project entitled “Cardiorespiratory Evaluation of Children with Post-Viral Bronchiolitis Obliterans.” The patients included in the present study were periodically followed-up at pediatric pulmonology outpatient clinics of the Brazilian Unified Health System (Sistema Único de Saúde [SUS]), referral services for the treatment of this disease in the city of Porto Alegre, state of Rio Grande do Sul, Brazil. The sample was recruited in the outpatient clinics, whereas the questionnaires and pulmonary function tests were performed in a third institution, a referral service for this type of examination.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Participants</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Inclusion criteria</span><p id="par0040" class="elsevierStylePara elsevierViewall">The study included a convenience sample of children and adolescents with a previous diagnosis of PIBO aged 8–16 years.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The diagnosis was based on the association of previously defined clinical, radiological, and functional criteria<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">11</span></a>: 1 – history of acute pulmonary infection in a previously healthy child younger than 2 years; 2 – persistent respiratory signs and symptoms four weeks after the initial event; 3 – high-resolution computed tomography showing alterations suggestive of bronchiolitis obliterans (BO), such as mosaic pattern, bronchiectasis, or atelectasis; 4 – airflow limitation by pulmonary function tests; 5 – exclusion of other chronic lung diseases that occur with persistent respiratory symptoms such as: severe asthma, cystic fibrosis, alpha-1-antitrypsin deficiency, and immunodeficiencies, among others.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Children with other chronic conditions that could compromise their quality of life were excluded. Healthy children were thus classified as they did not have any chronic diseases and did not use medication continuously. The children were selected in a public school due to social class similarities. The individuals in the control group were gender- and age-matched with the patient group.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Outcome variable</span><p id="par0055" class="elsevierStylePara elsevierViewall">The present study adopted HRQoL as the outcome variable.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Data source and measurements</span><p id="par0060" class="elsevierStylePara elsevierViewall">All evaluations of the present study, pulmonary function tests, and questionnaires were carried out at Hospital de Clínicas de Porto Alegre (HCPA).</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Pulmonary function test</span><p id="par0065" class="elsevierStylePara elsevierViewall">The technical procedures and the acceptability and reproducibility criteria for the performance of pulmonary function tests followed the guidelines of the American Thoracic Society.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">3</span></a> Spirometry was performed in a Master-Screen Jaeger equipment (CareFusion, Germany) and the following parameters were evaluated: forced vital capacity; %FVC; forced expiratory volume in the first second, %FEV<span class="elsevierStyleInf">1</span>; ratio between FEV<span class="elsevierStyleInf">1</span> and FVC, FEV<span class="elsevierStyleInf">1</span>/FVC; forced expiratory flow between 25% and 75% of FVC; and FEF<span class="elsevierStyleInf">25–75</span>%.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Data are shown as a percentage of the predicted value based on the Knudson reference values<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">10</span></a> for spirometry. All examinations were performed by the same technician and in the morning.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Health-related Quality of Life (HRQoL)</span><p id="par0075" class="elsevierStylePara elsevierViewall">The generic questionnaire PedsQL<span class="elsevierStyleSup">TM</span> 4.0, validated in Brazil, was applied to assess HRQoL.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">12,13</span></a> The tool includes 23 items that comprise the following domains: 1 – physical domain (eight items); 2 – emotional domain, (five items); 3 – social domain (five items); and 4 – school domain (five items). The PedsQL<span class="elsevierStyleSup">TM</span> 4.0 generic questionnaire consists of parallel self-assessment forms for children.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The evaluation of the children used in the present research includes the age groups of 8–12 and 13–18 years. The items refer to the evaluation of the previous month, and the child/adolescent respondents use a five-level response scale, in which 0<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>never a problem; 1<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>almost never a problem; 2<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>sometimes it is a problem; 3<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>is often a problem; and 4<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>almost always a problem. The PedsQL<span class="elsevierStyleSup">TM</span> was applied by the interviewer to children and adolescents. The items were inversely scored and linearly transposed into a 0–100 scale, in which 0<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>100, 1<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>75, 2<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>50, 3<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>25, 4<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0; thus, the higher the score, the better the HRQoL.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Bias</span><p id="par0085" class="elsevierStylePara elsevierViewall">To avoid possible measurement biases, all measurements were performed by the same evaluator, following the established standards for performing the examinations and applying the questionnaires. The children answered the questionnaire before the medical appointment, in the presence of the interviewer only.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Sample size</span><p id="par0090" class="elsevierStylePara elsevierViewall">Starting from a significant minimum difference of four points between the groups in the questionnaire, a standard deviation of 4, considering an alpha value of 5% and a beta of 20%, the minimum number of participants in each group was defined as 22.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Statistical analysis</span><p id="par0095" class="elsevierStylePara elsevierViewall">The distribution of variables was assessed using the Kolmogorov–Smirnov test. Continuous variables were shown as means and standard deviations, whereas the categorical variables were shown as absolute and relative frequencies. The comparison between the measures of quality of life and age was performed using Student's <span class="elsevierStyleItalic">t</span>-test for independent samples and the chi-squared test for the gender variable. The minimum significant difference considered in the PedsQL life questionnaire is 4 points. The level of significance was set at 5%. Data analysis was performed using SPSS (SPSS Statistics for Windows, Version 17.0, Chicago, USA).</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Ethical aspects</span><p id="par0100" class="elsevierStylePara elsevierViewall">The use of the research tool was previously authorized by the author of the PedsQL questionnaire. The project was approved by the Research Ethics Committee (REC) of the HCPA, in accordance with the current international and national standards and guidelines under No. 09-492. The participants’ parents or guardians signed the informed consent form and the children also expressed their willingness to participate in the research as suggested by the REC.</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Results</span><p id="par0105" class="elsevierStylePara elsevierViewall">A total of 34 patients diagnosed with PIBO and 34 controls participated in the study. The mean age of the children included in the study was 11.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.5 years; 39 (57.3%) were schoolchildren aged >12 years and 49 (72%) of them were males. The groups did not show any significant differences in relation to these variables. Regarding pulmonary function, PIBO patients had a mean percentage of the predicted value for forced vital capacity, forced expiratory volume in the first second, mean forced expiratory flow, and FEV<span class="elsevierStyleInf">1</span>/FVC of 88.97%, 77.21% 72.79% and 0.62, respectively, demonstrating pulmonary involvement (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The mean level of schooling of the parents of children with PIBO was 6.2 years.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">The quality of life score was significantly and clinically lower in the PIBO group compared to the control in the health (72.36<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>15.6 <span class="elsevierStyleItalic">vs.</span> 81.06<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>16.4, respectively; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.031) and school domains: (62.34<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>20.7 <span class="elsevierStyleItalic">vs.</span> 72.94<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>21.3, respectively; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.043) and in the total score (69.53<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>14.9 <span class="elsevierStyleItalic">vs.</span> 78.02<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>14.8, respectively; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.024; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Discussion</span><p id="par0115" class="elsevierStylePara elsevierViewall">The present study demonstrated that patients with PIBO present lower HRQoL scores than healthy individuals, in the total score and in the health and school domains.</p><p id="par0120" class="elsevierStylePara elsevierViewall">There is a scarcity of studies investigating quality of life impairment in PIBO patients. However, studies with other chronic obstructive pulmonary diseases, such as cystic fibrosis and asthma, have already demonstrated the HRQoL impairment in children.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a> A recent meta-analysis<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">15</span></a> assessed the quality of life of pediatric patients with asthma compared with healthy controls, using 15 studies published between 1994 and 2013.</p><p id="par0125" class="elsevierStylePara elsevierViewall">The study identified a decrease in the quality of life scores in children with asthma when compared to controls; the patients’ mean values were comparable to the present results in patients with PIBO.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">15</span></a> The similarity of HRQoL scores between patients with PIBO and asthma, in spite of the differences in disease severity, may be due to the sample of assessed children, which has received interdisciplinary care since the disease diagnosis, a factor that may have contributed to a greater control of the psychosocial factors related to the disease.</p><p id="par0130" class="elsevierStylePara elsevierViewall">A multicenter study carried out in Argentina showed a significant difference in values related to the quality of life in the school domain of patients with confirmed chronic diseases when compared with healthy children, most of which were asthmatic.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">16</span></a> The impact of the disease on the school and health domains has already been demonstrated even in patients with acute infectious events.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a> These findings promote the importance of the subjective viewpoint of these patients in different health domains in relation to disease impact. The ongoing study of HRQoL allows professionals from different areas to identify when it is necessary to intervene more specifically in these aspects of clinical practice.</p><p id="par0135" class="elsevierStylePara elsevierViewall">The minimum significant difference for PedsQL in children with health conditions is of four points for each domain.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a> The cutoff points for healthy patients with lower, moderate, and higher impairment have also been established. When analyzing the present results with the cutoff points described, it can be inferred that in the studied sample, the HRQoL impairment was moderate and that the difference between the means of the groups was clinically significant.</p><p id="par0140" class="elsevierStylePara elsevierViewall">This study has some limitations; first, the cross-sectional design of the study does not allow conclusions to be drawn regarding a causal association between BO and lower quality of life scores. Another limitation is that the assessed sample was chosen by convenience. Considering PIBO as a rare and chronic disease, the results appear to meet the hypothesis of the present study. These data allow a first diagnosis of HRQoL in patients with PIBO. Differences in quality of life between individuals with PIBO and their healthy peers could be attributed to the disease impairment, since the other characteristics of the control group were paired.</p><p id="par0145" class="elsevierStylePara elsevierViewall">Finally, due to the similarities between PIBO and severe asthma regarding symptoms and functional and imaging tests, the possibility that some patients may have both diseases cannot be completely discarded, despite fact that the chronic respiratory clinical picture was observed after the acute episode of PIBO.</p><p id="par0150" class="elsevierStylePara elsevierViewall">The authors conclude that patients with PIBO have lower HRQoL scores than healthy individuals in the total score and in the health and school domains. The present study reinforces the importance of the inclusion of a more subjective and multidimensional tool in the assessment of patients with BO.</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Funding</span><p id="par0155" class="elsevierStylePara elsevierViewall">CAPES and CNPQ provided grants to the postgraduate students.</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflicts of interest</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1062767" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1011118" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1062768" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1011119" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:11 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study design" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Context" ] 2 => array:3 [ "identificador" => "sec0025" "titulo" => "Participants" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Inclusion criteria" ] ] ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Outcome variable" ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Data source and measurements" ] 5 => array:2 [ "identificador" => "sec0045" "titulo" => "Pulmonary function test" ] 6 => array:2 [ "identificador" => "sec0050" "titulo" => "Health-related Quality of Life (HRQoL)" ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Bias" ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Sample size" ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Statistical analysis" ] 10 => array:2 [ "identificador" => "sec0070" "titulo" => "Ethical aspects" ] ] ] 6 => array:2 [ "identificador" => "sec0075" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0080" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0085" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0090" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-04-07" "fechaAceptado" => "2017-05-31" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1011118" "palabras" => array:3 [ 0 => "Health-related quality of life" 1 => "Bronchiolitis obliterans" 2 => "Children" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec1011119" "palabras" => array:3 [ 0 => "Qualidade de vida relacionada à saúde" 1 => "Bronquiolite Obliterante" 2 => "Crianças" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To evaluate the overall health-related quality of life in patients with bronchiolitis obliterans.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Participants with a diagnosis of post-infectious bronchiolitis obliterans, who were being followed-up at two specialized outpatient clinics of Pediatric Pulmonology in Porto Alegre, Brazil, and controls aged between 8 and 17 years, of both genders, were included in the study. Controls were paired by gender, age, and socioeconomic level in relation to the group of participants with post-infectious bronchiolitis obliterans. The version of the Pediatric Quality of Life Inventory (PedsQ) tool validated for Brazil was applied for the assessment of Health-related Quality of Life, through an interview. The comparison of the Health-related Quality of Life means between the groups was performed using Student's <span class="elsevierStyleItalic">t</span>-test for independent samples and the chi-squared test, for categorical variables.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">34 patients diagnosed with post-infectious bronchiolitis obliterans and 34 controls participated in the study. The mean age of the children included in the study was 11.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.5 years, and 49 (72%) of them were males. The groups showed no significant differences in relation to these variables. The quality of life score was significantly and clinically lower in the post-infectious bronchiolitis obliterans group when compared with controls in the health (72.36<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>15.6, 81.06<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>16.4, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.031) and school domains (62.34<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>20.7, 72.94<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>21.3, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.043), as well as in the total score (69.53<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>14.9, 78.02<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>14.8, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.024), respectively.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Patients with post-infectious bronchiolitis obliterans presented lower health-related quality of life scores when compared with healthy individuals in the total score and in the health and school domains.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Avaliar a qualidade de vida relacionada à saúde geral em participantes com bronquiolite obliterante.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Foram incluídos no estudo participantes com diagnóstico de bronquiolite obliterante pós-infecciosa que estavam em acompanhamento em dois ambulatórios especializados de pneumologia pediátrica em Porto Alegre, Brasil e controles, com idades entre 8 e 17 anos, de ambos os sexos. Os controles foram pareados por sexo, idade e nível socioeconômico em relação ao grupo de participantes com bronquiolite obliterante pós-infecciosa. Para avaliação da Qualidade de Vida Relacionada à Saúde geral foi aplicado a versão validada para o Brasil do instrumento PedsQL (<span class="elsevierStyleItalic">Pediatric Quality of Life Inventory)</span>, por meio de entrevista. A comparação entre as médias da Qualidade de Vida Relacionada à Saúde entre os grupos foi realizada mediante o teste <span class="elsevierStyleItalic">t</span> para amostras independentes e para as variáveis categóricas por teste Qui-quadrado.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Participaram do estudo 34 pacientes com diagnóstico de bronquiolite obliterante pós-infecciosa e 34 controles. A média da idade das crianças incluídas foi 11,2 ± 2,5 anos e 49 (72%) deles eram do sexo masculino. Os grupos não apresentaram diferenças significativas em relação a essas variáveis. O escore de qualidade de vida foi significativamente e clinicamente menor no grupo bronquiolite obliterante pós-infecciosa em comparação com o controle nos domínios saúde: (72,36 ± 15,6; 81,06 ± 16,4; p = 0,031); escolar: (62,34 ± 20,7; 72,94 ± 21,3; p = 0,043) e no escore total (69,53 ± 14,9; 78,02 ± 14,8, p = 0,024), respectivamente.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusão</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Concluímos que os pacientes com bronquiolite obliterante pós-infecciosa apresentam escores de qualidade de vida relacionados à saúde menor que indivíduos saudáveis no escore total e nos domínios saúde e escolares.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as: Sarria EE, Mundstock E, Machado DG, Mocelin HT, Fischer GB, Furlan SP, et al. Health-related quality of life in patients with bronchiolitis obliterans. J Pediatr (Rio J). 2018;94:374–9.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Study carried out at Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Universidade Federal do Rio Grande do Sul (UFRGS), Centro Universitário Ritter dos Reis (UniRitter), Porto Alegre; and Universidade de Santa Cruz do Sul (UNISC), Santa Cruz do Sul, RS, Brazil.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">PIBO, post-infectious bronchiolitis obliterans; SD, standard deviation; FVC, percentage of the predicted for forced vital capacity; FEV<span class="elsevierStyleInf">1</span>, percentage of the predicted for forced expiratory volume in the first second; FEF<span class="elsevierStyleInf">25–75%</span>, percentage of the predicted for the mean forced expiratory flow.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PIBO (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>34) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Control (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>34) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gender, (male), <span class="elsevierStyleItalic">n</span> (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 (79.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 (64.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.280<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (years), mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.82<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.82<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.000<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age range (≥12 years), <span class="elsevierStyleItalic">n</span> (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (55.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (58.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.500<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">FVC (%), mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88.97<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>19.64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">FEV<span class="elsevierStyleInf">1</span> (%), mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77.21<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>22.50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">FEF<span class="elsevierStyleInf">25–75%</span> (%), mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">72.79<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>22.79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">FEV<span class="elsevierStyleInf">1/</span>FVC, mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.62<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1812063.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Student's <span class="elsevierStyleItalic">t</span>-test for independent samples.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Chi-squared test.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Sample characteristics.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">PIBO, post-infectious bronchiolitis obliterans; SD, standard deviation; 95% CI, 95% confidence interval for the difference.</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Student's <span class="elsevierStyleItalic">t</span>-test for independent samples.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Domain \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PIBO (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>34) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Control (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>34) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Difference (95% CI) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-Value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Health, mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">72.36<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>15.65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81.06<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>16.48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−8.7 (−16.6 to −0.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.031<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Emotional, mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61.25<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>22.10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68.52<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>20.72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−7.2 (−17.8 to 3.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.172 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Social, mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">80.46<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>19.52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">87.79<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>17.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−7.3 (−16.4 to 1.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.113 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">School, mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62.34<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>20.27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">72.94<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>21.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−10.5 (−20.8 to −0.35) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.043<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Psychosocial, mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70.85<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>17.24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">78.12<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>16.27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−7.2 (−15.5 to 0.99) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.083 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total score, mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69.53<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>14.99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">78.02<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>14.87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−8.4 (−15.8 to −1.14) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.024<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1812064.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0015"><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Quality of life score by domain.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0095" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hypoxemia is an independent predictor of bronchiolitis obliterans following respiratory adenoviral infection in children" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P.-Q. Wu" 1 => "X. Li" 2 => "W.-H. Jiang" 3 => "G.-Q. Yin" 4 => "A.-H. Lei" 5 => "Q. Xiao" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Springerplus" "fecha" => "2016" "volumen" => "51" "paginaInicial" => "1622" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0100" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Postinfectious bronchiolitis obliterans in children: the South American contribution" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.A. Castro-Rodriguez" 1 => "V. Giubergia" 2 => "G.B. Fischer" 3 => "C. Casta" 4 => "E.E. Sarria" 5 => "R. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 4 | 6 |
| 2024 October | 19 | 22 | 41 |
| 2024 September | 19 | 33 | 52 |
| 2024 August | 25 | 23 | 48 |
| 2024 July | 60 | 27 | 87 |
| 2024 June | 35 | 15 | 50 |
| 2024 May | 27 | 8 | 35 |
| 2024 April | 75 | 20 | 95 |
| 2024 March | 40 | 18 | 58 |
| 2024 February | 14 | 21 | 35 |
| 2024 January | 16 | 21 | 37 |
| 2023 December | 13 | 26 | 39 |
| 2023 November | 17 | 24 | 41 |
| 2023 October | 18 | 26 | 44 |
| 2023 September | 19 | 32 | 51 |
| 2023 August | 14 | 22 | 36 |
| 2023 July | 15 | 15 | 30 |
| 2023 June | 20 | 9 | 29 |
| 2023 May | 21 | 15 | 36 |
| 2023 April | 16 | 7 | 23 |
| 2023 March | 38 | 21 | 59 |
| 2023 February | 28 | 14 | 42 |
| 2023 January | 17 | 23 | 40 |
| 2022 December | 34 | 25 | 59 |
| 2022 November | 35 | 23 | 58 |
| 2022 October | 33 | 37 | 70 |
| 2022 September | 22 | 30 | 52 |
| 2022 August | 20 | 31 | 51 |
| 2022 July | 22 | 30 | 52 |
| 2022 June | 20 | 27 | 47 |
| 2022 May | 18 | 26 | 44 |
| 2022 April | 28 | 35 | 63 |
| 2022 March | 26 | 49 | 75 |
| 2022 February | 13 | 16 | 29 |
| 2022 January | 14 | 16 | 30 |
| 2021 December | 14 | 19 | 33 |
| 2021 November | 13 | 19 | 32 |
| 2021 October | 12 | 18 | 30 |
| 2021 September | 9 | 13 | 22 |
| 2021 August | 4 | 13 | 17 |
| 2021 July | 5 | 4 | 9 |
| 2021 June | 10 | 12 | 22 |
| 2021 May | 9 | 14 | 23 |
| 2021 April | 8 | 22 | 30 |
| 2021 March | 4 | 6 | 10 |
| 2021 February | 4 | 6 | 10 |
| 2021 January | 7 | 9 | 16 |
| 2020 December | 13 | 9 | 22 |
| 2020 November | 8 | 10 | 18 |
| 2020 October | 4 | 6 | 10 |
| 2020 September | 15 | 8 | 23 |
| 2020 August | 6 | 2 | 8 |
| 2020 July | 3 | 4 | 7 |
| 2020 June | 6 | 3 | 9 |
| 2020 May | 3 | 3 | 6 |
| 2020 April | 5 | 11 | 16 |
| 2020 March | 5 | 5 | 10 |
| 2020 February | 16 | 10 | 26 |
| 2020 January | 13 | 13 | 26 |
| 2019 December | 15 | 8 | 23 |
| 2019 November | 13 | 5 | 18 |
| 2019 October | 22 | 14 | 36 |
| 2019 September | 11 | 6 | 17 |
| 2019 August | 14 | 10 | 24 |
| 2019 July | 11 | 10 | 21 |
| 2019 June | 13 | 17 | 30 |
| 2019 May | 22 | 10 | 32 |
| 2019 April | 26 | 8 | 34 |
| 2019 March | 23 | 13 | 36 |
| 2019 February | 19 | 8 | 27 |
| 2019 January | 16 | 6 | 22 |
| 2018 December | 19 | 6 | 25 |
| 2018 November | 19 | 3 | 22 |
| 2018 October | 42 | 14 | 56 |
| 2018 September | 23 | 8 | 31 |
| 2018 August | 29 | 20 | 49 |
| 2018 July | 28 | 14 | 42 |
| 2018 June | 3 | 2 | 5 |
| 2018 May | 3 | 20 | 23 |
| 2018 April | 1 | 4 | 5 |
| 2018 March | 5 | 10 | 15 |
| 2018 February | 2 | 4 | 6 |
| 2018 January | 0 | 7 | 7 |
| 2017 December | 0 | 14 | 14 |
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