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Time dedicated to physical activity among medical residents: are there differences based on gender or specialty type?
Tiempo dedicado a la actividad física entre los residentes médicos: ¿existen diferencias basadas en el género o el tipo de especialidad?
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"tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "387" "paginaFinal" => "392" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Time dedicated to physical activity among medical residents: are there differences based on gender or specialty type?" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 761 "Ancho" => 2183 "Tamanyo" => 66975 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Gráfico que compara el tiempo dedicado a la actividad física en una semana normal entre residentes quirúrgicos y clínicos y residentes hombres y mujeres. Los residentes de cirugía y los hombres practicaron significativamente más horas de AF.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "O. Pujol, L. Vila-Castillo, C. Álvaro, M. Aguilar, N. Joshi, J. Minguell" "autores" => array:6 [ 0 => array:2 [ "nombre" => "O." "apellidos" => "Pujol" ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Vila-Castillo" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Álvaro" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Aguilar" ] 4 => array:2 [ "nombre" => "N." "apellidos" => "Joshi" ] 5 => array:2 [ "nombre" => "J." 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The 30-day mortality rates in the referral and internal validation cohorts(22) and those in our cohort were compared. The colors for each series are shown in the graphic’s legend.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "S. Goya-Lirio, M. Hernando-Llorens, S. García de Garayo-Díaz, J. Regalado-de Los Cobos" "autores" => array:4 [ 0 => array:2 [ "nombre" => "S." "apellidos" => "Goya-Lirio" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Hernando-Llorens" ] 2 => array:2 [ "nombre" => "S." "apellidos" => "García de Garayo-Díaz" ] 3 => array:2 [ "nombre" => "J." 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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "387" "paginaFinal" => "392" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "O. Pujol, L. Vila-Castillo, C. Álvaro, M. Aguilar, N. Joshi, J. Minguell" "autores" => array:6 [ 0 => array:4 [ "nombre" => "O." "apellidos" => "Pujol" "email" => array:1 [ 0 => "oriolp-6@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "L." "apellidos" => "Vila-Castillo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "C." "apellidos" => "Álvaro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "Aguilar" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "N." "apellidos" => "Joshi" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "J." "apellidos" => "Minguell" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Orthopaedic Surgery Department, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Sant Joan de Deu University Hospital, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tiempo dedicado a la actividad física entre los residentes médicos: ¿existen diferencias basadas en el género o el tipo de especialidad?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1472 "Ancho" => 2175 "Tamanyo" => 107714 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Graphic comparing the time dedicated to PA in a regular week between surgical vs clinical residents and men vs women residents. Surgical and men residents practiced significantly more hours of PA.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">A medical resident is a physician who has already finished the medical degree and is completing additional training in its specialty of choice. In Spain, generally, surgical specialties residencies last five years while the clinical ones last four years. During this period, residents may be subjected to sleep deprivation, high workload and extended work schedule; burnout prevalence has been found to be as high as 35.7%.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> According to the Spanish General Council of Official Colleges of Physicians, more than 80% of the 32,000 Spanish medical residents work more than 48 h/week and are on-call more than four days per month.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Moreover, more than 10% of the 24-h on-call shifts are not followed by the mandatory resting period. These conditions place medical residents at especially high risk of neglecting their personal health and restricting time dedicated to physical activity (PA).</p><p id="par0010" class="elsevierStylePara elsevierViewall">The PA Guidelines for Americans<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> reported that adults should do at least 2,5−5 h a week of moderate-intensity aerobic PA and should also do muscle-strengthening activities twice a week. PA is important for preventing several chronic diseases such as diabetes, cancer, hypertension, obesity or osteoporosis.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> It has also been linked to psychological well-being and happiness.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Moreover, the PURE study<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> defended that increasing PA is a simple, widely applicable and low-cost strategy associated with lower risk of cardiovascular disease and mortality.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Despite the affluence of research studying the benefits of PA, few articles have investigated the PA practice among physicians in training period. In Spain, the 21.1% of the young population have a sedentary lifestyle.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> However, this rate may be higher among medical residents due to the overwork, limited free time and fatigue. A study performed in Puerto Rico reported that a considerable number of their residents (41.3%) did not perform any PA in their leisure time.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Similarly, another study from Saudi Arabia showed that the 68.4% of the medical residents had low levels of PA.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Two USA investigations concluded that the high work hour demands of physicians in training was strongly associated with inactivity.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a> However, it is still controversial if type of residency or gender can potentially influence on time dedicated to PA.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9,12</span></a> Additionally, no study has analyzed the PA practice among medical residents from Spain.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The objective of the present study was to analyze the time dedicated to PA among medical residents, comparing women vs men residents and surgical vs clinical residents.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study design</span><p id="par0025" class="elsevierStylePara elsevierViewall">After institutional review board approval (PR(AT)82/2022), a cross-sectional study was performed. A web-based questionnaire was designed to study the PA practice of medical residents from our hospital. All medical residents from our institution were invited to voluntarily participate in the study through a corporate mail sent on June 2022. The residents received a document with information about the study. If they agreed to participate, they were asked to complete the web-based self-administered survey during the following month. All responses were included in the study database. The exclusion criteria included not being a medical resident from our institution, being younger than 24 years old (minimum age to initiate the residence) or older than 65 years old and self-reporting being physically impaired to exercise.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Our institution is a Spanish third-level hospital which has 550 medical residents. Medical specialties are divided between surgical and clinical. In Spain, generally, surgical specialties residencies last five years while the clinical ones last four years. The number of residents per specialty is variable (from one to eighteen). The institution does not have its own sport facilities. However, it is linked to some nearby sport centers that provide advantageous conditions for their workers.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Outcome variables</span><p id="par0035" class="elsevierStylePara elsevierViewall">The following data were recorded: a) Demographics (age and gender), b) Residency (specialty, surgical/clinical and year of residency) and c) Physical activity (self-consider to practice PA regularly, number of hours dedicated to PA in a regular week and type of PA performed).</p><p id="par0040" class="elsevierStylePara elsevierViewall">PA was considered as any activity that improves or maintains the physical qualities (strength, speed, resistance, flexibility and coordination), health and well-being of a person.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Firstly, the time dedicated to PA among medical residents was described using the number of hours of PA in a regular week, the self-perception of practice PA regularly and type of PA performed. Secondly, the amount of time dedicated to PA was compared between different subgroups: surgical vs clinical residents and women vs men residents.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical analysis</span><p id="par0050" class="elsevierStylePara elsevierViewall">Demographic factors and clinical characteristics were summarized as counts and percentages for categorical variables. Means were calculated for continuous variables. Normality was tested using the Kolmogorov-Smirnov test. Groups were compared using the χ2 test for categorical variables. Continuous variables were evaluated with the student’s T test. To analyze the relationship between different variables and rule out confounding bias, an Analysis of Covariance (ANCOVA) and a regression model were used. The dependent variable was time dedicated to PA. Independent variables include gender, specialty type, age and year of residency. All p-values were two-tailed. A p-value <0.05 was considered statistically significant. Statistical analysis was performed using SPSS®️ v.21.0 software (IBM Corp. Armonk, NY, USA).</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">After review of our database, 114/550 (20.73%) medical residents from our institution voluntarily participated in the study and completed the questionnaire. The 57.9% were women and mean age was 27.89 ± 2.98 years (range 24–42). There were 70 (61.4%) clinical residents and 44 (38.6%) surgical residents. Classification of participants according to the year of residency was: first year (40, 35.1%), second year (19, 16.7%), third year (5, 4.4%), fourth year (36, 31.6%) and fifth year (14, 12.3%).</p><p id="par0060" class="elsevierStylePara elsevierViewall">The 32.5 % of the residents answered that they consider not to be practicing PA regularly. Mean time dedicated to PA in a regular week was 3.62 ± 2.22 h (range: 0–10). The 50% of the residents dedicated less than 3.5 h to PA. The most usual types of PA practiced were gym-based training (52.6%), jogging (31.6%) and yoga (19.3%), (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Men residents dedicated more time to PA in a regular week than women residents 4.23 ± 2.42 h vs 3.14 ± 1.95 h (p = 0.012), (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> and <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Surgical residents dedicated more time to PA than clinical residents: 4.33 ± 2.36 h vs 3.23 ± 2.05 h (p = 0.01). However, there were no differences in time according to the year of residency (p > 0.05) or age (p > 0.05).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The groups (women vs men and surgical vs clinical) were comparable in terms of age and year of residency distribution. There were more women residents among the clinical specialties: 67.1% vs 41.5% (p = 0.008). Nonetheless, the regression model elucidated the statistically significant independent contribution of both gender (p = 0.04) and specialty type (p = 0.03) to variations in time dedicated to PA. Importantly, the analysis of covariance revealed a non-significant between-subject effects test for the interaction between gender and specialty type (p = 0.196), suggesting that the observed differences in PA between specialties were not merely a result of the higher proportion of men among surgeons.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">The most important finding of our study was that the 32.5% of the residents considered themselves to be physically inactive and mean time dedicated to PA in a regular week was 3.6 ± 2.2 h. Men and surgical residents practice PA more time than women and clinical residents (4.2 ± 2.4 vs 3.1 ± 1.9 h (p = 0.012) and 4.3 ± 2.3 vs 3.2 ± 2.0 h (p = 0.01) respectively.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Although there is not a strict minimum level of recommended PA, the PA Guidelines for Americans<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> reported that adults should do at least 2,5−5 h a week of moderate-intensity aerobic PA (although additional health benefits are gained for >5 h) and should also do muscle-strengthening activities twice a week. Therefore, there is a relevant percentage of Spanish medical residents who do not perform enough PA regularly. It is well described that PA is associated with positive health outcomes such as prevention of several chronic diseases, improved cardiovascular status and enhanced mental health.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> It has also been demonstrated that residents who engage high level of regular PA are less likely to be burned out.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Furthermore, physicians who exercise regularly present improved work performance and are more likely to counsel patients on the benefits of PA.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Another study also found that decreased exercise frequency was correlated with lower professional efficacy and higher burnout risk.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> For all these reasons, the high percentage of medical residents who are not regularly engaged to PA is worrying.</p><p id="par0085" class="elsevierStylePara elsevierViewall">According to the Spanish National Institute of Statistics (INE),<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> the 21.1% of the general Spanish population of the same age group than the cohort study group have a sedentary lifestyle. In our study of medical residents, we found a higher rate of participants considering themselves not to be practicing PA regularly (32.5%). It may be explained by the high workload, extended work schedule, limited personal time and sleep deprivation that medical residents face during their training period. Moreover, some residents consider formation and work more priority than PA<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Stacchini et al.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> found that a relevant percentage of residents suffer high work-to-private life interference, which was associated with increased risk of clinically relevant depressive symptoms.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Low level of PA practice among medical residents do not seem to occur exclusively in Spain, probably due to similar demographic characteristics and working conditions. Residents often disregard their health in order to improve their medical training and benefit their patients. A study performed in Puerto Rico also reported that a considerable number of their residents (41.3%) did not perform any PA in their leisure time.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Furthermore, the 96.2% of the residents reported not having received adequate education regarding PA guidelines. The authors highlighted that a plan of action to increase knowledge in PA guidelines may be warranted to contribute to residents health. Similarly, a study from Saudi Arabia showed that the 68.4% of the medical residents had low levels of PA.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Some of the reported barriers for practicing PA were no enough time, limited exercise facilities nearby and not considering PA a priority. An USA study determined that residents and fellow physicians engaged in less PA than attending physicians and medical students.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> They concluded that the high work hour demands of physicians in training was strongly associated with the inactivity. Another article studying Americans medical residents reported that the residency period was associated with a significant decrease in PA attributed to time constraints.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Furthermore, they found residents calculated fitness age to be 5.6 years higher than their chronological age. A South Korean study found that BMI, blood pressure, liver function and cholesterol level significantly worsen during the training period.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Interestingly, they also detected that shorter working hours were associated with lower smoking and drinking habit and high regular exercise rate.</p><p id="par0095" class="elsevierStylePara elsevierViewall">In our study, men residents dedicated more time to PA than women residents: 4.23 ± 2.42 h vs 3.14 ± 1.95 h (p = 0.012). Unfortunately, this finding was uniform in the literature. Similar to us, in Canada, they also found that male residents spent more time exercising than women residents (4.4 vs 3.4 h per week).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> In the Puerto Rico’s study, men residents were more likely to perform regular exercise and meet the PA guidelines recommendations (67% vs 47%).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In the investigation performed in Saudi Arabia, female residents reported lower level of PA due to limited time and lack of suitable places to exercise nearby.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Another important outcome of our study was that surgical residents dedicated significantly more time to PA in a regular week than clinical residents: 4.33 ± 2.36 h vs 3.23 ± 2.05 h (p = 0.01). In a Canadian study, surgical and clinical residents showed no differences in reported hours of exercise per week (4.2 ± 2.6 vs 3.9 ± 2.5), despite the surgical residents worked more hours in the hospital.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> However, longer work hours was associated with lower aerobic fitness and increased BMI and body fat of surgical residents. The increased time dedicated to PA by surgical residents may be multifactorial. One reason could be that surgeons tend to be physically more active. Bellodi<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> analyzed why trainees chose surgical or clinical residencies; they found that surgeons appreciate practical interventionism and manual activities while general physicians preferred intellectual activities and knowledge. Although both surgical and clinical residents suffer long work hours, it seems that surgeons give more importance to the practice of PA during their limited leisure time.</p><p id="par0105" class="elsevierStylePara elsevierViewall">We think that it is very important that all medical residents develop a healthy lifestyle through self-care, proper sleep cycle, nutrition and regular PA to benefit their long-term physical, mental and emotional health. Furthermore, overall resident health is important professionally to improve work performance and promote a healthy lifestyle to their patients. Efforts should be made to encourage PA in this population, especially in women and clinical residents, through personal PA enjoyment, flexible work schedules and providing suitable places to practice PA near the health facilities. The implementation of a PA program for medical residents in the hospital may also have an important role. PA programs provide an structured and organized planning to engage PA. Roger et al.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> demonstrated that a PA program can be feasible and well accepted by the residents, improving their knowledge and attitude towards PA.</p><p id="par0110" class="elsevierStylePara elsevierViewall">We recognize there are limitations to our study. First, the medical residents of our hospital may not have been homogeneously represented in the study due to the limited response rate. However, we checked that study groups were comparable and we have performed a regression model to demonstrate the independent contribution of each variable. Second, the study relies on self-reported outcomes. The authors defend that participant reported outcomes may be useful and reliable to obtain real-world data. Third, it is a single-center study with a relatively small sample, which can limit the generalizability of our findings. However, residency training program and its requirements are similar among the different hospitals belonging to the public Spanish health system. Furthermore, our findings are comparable to those obtained in similar studies analyzing residents from other countries.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusion</span><p id="par0115" class="elsevierStylePara elsevierViewall">One third of the medical residents consider themselves physically inactive. Women and clinical residents practice PA less time than men and surgical residents. Efforts should be made to encourage PA among residents, especially in women and non-surgeons.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Funding</span><p id="par0120" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public, commercial or non-profit sectors.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that they have no competing interests.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Ethics approval</span><p id="par0130" class="elsevierStylePara elsevierViewall">The study was approved by our Center’s Ethics Committee (CEIC). The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Consent to participate</span><p id="par0135" class="elsevierStylePara elsevierViewall">Informed consent was obtained from all individual participants included in the study.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:3 [ "identificador" => "xres2162644" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1834685" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2162643" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1834684" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study design" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Outcome variables" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of interest" ] 11 => array:2 [ "identificador" => "sec0055" "titulo" => "Ethics approval" ] 12 => array:2 [ "identificador" => "sec0060" "titulo" => "Consent to participate" ] 13 => array:2 [ "identificador" => "xack750558" "titulo" => "Acknowledgements" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2024-04-16" "fechaAceptado" => "2024-04-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1834685" "palabras" => array:6 [ 0 => "Exercise" 1 => "Physical activity" 2 => "Health" 3 => "Medical residents" 4 => "Spain" 5 => "Gender" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1834684" "palabras" => array:6 [ 0 => "Ejercicio" 1 => "Actividad física" 2 => "Salud" 3 => "Residentes médicos" 4 => "España" 5 => "Género" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Physical activity (PA) is associated with positive health outcomes such as prevention of chronic diseases, psychological well-being and improved work performance. Medical residents are subjected to sleep deprivation, extended work schedule and high burnout prevalence. These conditions may lead to the neglect of personal health and the restriction of time dedicated to PA. The objective of the present study was to analyze the time dedicated to PA of medical residents, comparing women vs men residents and surgical vs clinical residents.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">It is a cross-sectional study performed in a Spanish third-level university hospital. All medical residents from our institution were invited to voluntarily participate in the study answering a web-based questionnaire on June 2022. Data regarding demographics, residency and PA practice was recorded.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The response rate was 20.73% (114/550). The 32.5% of the residents considered themselves to be physically inactive and mean time dedicated to PA in a regular week was 3.62 ± 2.22 h. Men residents dedicated more time to PA than women residents (4.23 ± 2.42 h vs 3.14 ± 1.95 h, p = 0.012) and surgical residents dedicated more time than clinical residents (4.33 ± 2.36 h vs 3.23 ± 2.05 h, p = 0.01).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">One third of the medical residents consider themself physically inactive. Women and clinical residents practice PA less time than men and surgical residents. Efforts should be made to encourage PA among residents, especially in women and non-surgeons.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La actividad física (AF) está asociada a efectos de salud positivos como la prevención de enfermedades crónicas, el bienestar psicológico y el mejor rendimiento laboral. Los médicos residentes están sujetos a privación de sueño, horarios de trabajo prolongados y una alta prevalencia de agotamiento. Estas condiciones pueden llevar al descuido de la salud personal y a la restricción del tiempo dedicado a la AF. El objetivo del presente estudio es analizar el tiempo dedicado a la AF de los médicos residentes, comparando a las residentes mujeres vs hombres y a los residentes quirúrgicos vs clínicos.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Se trata de un estudio transversal realizado en un hospital universitario de tercer nivel en España. Todos los médicos residentes de nuestra institución fueron invitados a participar voluntariamente en el estudio respondiendo a un cuestionario en línea en junio de 2022. Se registraron datos demográficos, de residencia y práctica de AF.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La tasa de respuesta fue del 20.73% (114/550). El 32.5% de los residentes se consideraban físicamente inactivos y el tiempo medio dedicado a la AF en una semana regular fue de 3.62 ± 2.22 horas. Los residentes hombres dedicaron más tiempo a la AF que las residentes mujeres (4.23 ± 2.42 horas vs 3.14 ± 1.95 horas, p = 0.012) y los residentes quirúrgicos dedicaron más tiempo que los residentes clínicos (4.33 ± 2.36 horas vs 3.23 ± 2.05 horas, p = 0.01).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Un tercio de los médicos residentes se consideran físicamente inactivos. Las mujeres y los residentes clínicos practican menos AF que los hombres y los residentes quirúrgicos. Se deben hacer esfuerzos para fomentar la AF entre los residentes, especialmente en las mujeres y los no cirujanos.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1472 "Ancho" => 2175 "Tamanyo" => 107714 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Graphic comparing the time dedicated to PA in a regular week between surgical vs clinical residents and men vs women residents. Surgical and men residents practiced significantly more hours of PA.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\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">Type of physical activity \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">Residents (N [%]) \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">Gym-based training \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 (52.6%) \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">Jogging \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 (31.6%) \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">Yoga \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">22 (19.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Racket sports \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 (15.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Swimming \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 (13.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spinning \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">11 (9.6%) \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">Team sports (soccer, basketball, etc.) \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">11 (9.6%) \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">Cycling \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 (7.9%) \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">Climbing \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 (4.4%) \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">Combat sports \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 (2.6%) \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">Hiking \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 (1.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dancing \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 (1.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Skating \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 (1.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3563660.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Number and percentage of residents that practice each type of PA. When answering this question in the survey, residents could choice multiple options.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "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="\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">Variable \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">Association with time dedicated to PA (p-value) \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">Specialty type (surgical vs clinical) \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">P = 0.01<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \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">Gender (men vs women) \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">P = 0.012<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \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">Year of residency \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">P > 0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age \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">P > 0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3563659.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Statistically significant differences were considered if p < 0.05.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Analysis of variables that may influence time dedicated to PA among medical residents.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Burnout syndrome among medical residents: a systematic review and meta-analysis. 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We also thank our institution for helping us in the questionnaire distribution.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/22548874/0000022400000006/v1_202406100423/S2254887424000651/v1_202406100423/en/main.assets" "Apartado" => array:4 [ "identificador" => "1901" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original Articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/22548874/0000022400000006/v1_202406100423/S2254887424000651/v1_202406100423/en/main.pdf?idApp=WRCEE&text.app=https://revclinesp.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887424000651?idApp=WRCEE" ]
