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Fournier Gangrene: Description of 37 Cases and Analysis of Associated Health Care Costs
Gangrena de Fournier. Análisis descriptivo y coste económico-sanitario de nuestra serie de 37 casos
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Análisis descriptivo y coste económico-sanitario de nuestra serie de 37 casos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 878 "Ancho" => 750 "Tamanyo" => 145266 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Reconstruction of the genital area and covering with skin after debridement.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Fournier gangrene is a urological emergency that was first reported in 1764 by Baurienne,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> although it was not until 1883 that the French venereologist Jean Fournier described the clinical characteristics of the disease in a series of 5 cases with no apparent cause.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Fournier gangrene is defined as necrotizing fasciitis resulting from a rapidly progressive polymicrobial infection involving aerobes and anaerobes acting synergistically. The disease originates in the anorectal and genitourinary areas and can reach the groin, legs, anterior wall of the abdomen, and even the thorax, given its ability to progress across the fasciae of Buck, Dartos, Colles, and Scarpa.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Progression results from thrombosis of the small subcutaneous vessels secondary to endarteritis obliterans, which produces tissue hypoxia and limited vascular supply, thus facilitating overgrowth of anaerobic microorganisms and making it difficult for antibiotics to reach these areas.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Although there have been reports in women and even in children as young as 2 months,<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> the disease mainly affects men aged 50–70 years.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The overall incidence of the disease is 1.6 cases per 100<span class="elsevierStyleHsp" style=""></span>000 person-years,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> although mortality is high (20%–30%, on average,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> according to recent series), despite initiation of appropriate treatment, which consists of adequate hemodynamic stabilization, early and radical debridement, broad-spectrum antibiotic therapy, and daily wound care.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Many patients have underlying systemic diseases (e.g., diabetes mellitus, urogenital tuberculosis, syphilis, human immunodeficiency virus infection, cancer, and chronic alcoholism), which are responsible for the vascular and immune disorders that increase susceptibility to polymicrobial infection.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Low socioeconomic level has also been reported to be a predisposing factor.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Using data from the patients treated in our department, we analyzed the clinical and epidemiological characteristics of Fournier gangrene to compare them with the findings of previous reports. We also analyzed those variables that affected outcome and mortality.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Material and Methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">We retrospectively analyzed 37 patients diagnosed with Fournier gangrene at Hospital Universitario San Cecilio in Granada, Spain between January 2001 and October 2010. The disease was coded according to the <span class="elsevierStyleItalic">International Classification of Diseases, Ninth Revision</span> as Fournier gangrene (728.86). Clinical diagnosis was based on the patient's medical history and physical examination, which included as diagnostic criteria the presence of foul-smelling necrotic slough in the anogenital area associated with crepitus in the context of sepsis.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The variables studied were as follows:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0050" class="elsevierStylePara elsevierViewall">Personal details: age and sex.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0055" class="elsevierStylePara elsevierViewall">Personal history, including mainly presence of diabetes mellitus, chronic alcoholism, obesity, perianal abscess or fistula, and urethral stricture.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0060" class="elsevierStylePara elsevierViewall">Presence or absence of previous multiple conditions. We defined multiple conditions as the presence of 2 or more chronic diseases that can affect normal performance of activities of daily living and require close follow-up by a clinician.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0065" class="elsevierStylePara elsevierViewall">Urinary catheterization before diagnosis of Fournier gangrene.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5.</span><p id="par0070" class="elsevierStylePara elsevierViewall">Identification of causal agents (monomicrobial or polymicrobial).</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6.</span><p id="par0075" class="elsevierStylePara elsevierViewall">Need for reconstructive surgery: secondary suture, placement of skin grafts or flaps.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7.</span><p id="par0080" class="elsevierStylePara elsevierViewall">Outcome (mortality attributable to infection).</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8.</span><p id="par0085" class="elsevierStylePara elsevierViewall">Admission to and length of stay in the intensive care unit (ICU).</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9.</span><p id="par0090" class="elsevierStylePara elsevierViewall">Length of hospital stay.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10.</span><p id="par0095" class="elsevierStylePara elsevierViewall">Mean overall health care costs arising mainly from the hospital stay and the use of an operating room for wound care. The cost was calculated using Coan-HyD, the cost calculation program used by the Andalusian Health Service.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> We calculated the unit cost, which was defined as the total cost (direct costs<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>indirect costs) divided into product units (i.e., stay in the ICU, stay on the urology ward, and time [hours] in the operating room) for a stay in the ICU (€1609.65 per day), a stay on the urology ward (€373.82 per day), and hours of operating room time with 1 surgeon (€884.05 per hour). Each unit cost was multiplied by the mean stay in the ICU, the mean stay on the urology ward, and the mean time in the operating room.</p></li></ul></p><p id="par0100" class="elsevierStylePara elsevierViewall">Data were analyzed in a purpose-designed database using SPSS version 17.0 and by applying the <span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span> test or the <span class="elsevierStyleItalic">t</span> test, as appropriate. Statistical significance was set at <span class="elsevierStyleItalic">P</span>≤.05.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0105" class="elsevierStylePara elsevierViewall">We analyzed 37 patients diagnosed with Fournier gangrene during the study period. Mean (SD) age was 57.68 (15.56) years. As for personal history, 21.6% of patients had chronic alcoholism, 43.2% had diabetes (insulin-dependent or not), and 24.3% had had some degree of ischemic heart disease. Local involvement of the genital and perineal areas was as follows: urethral stricture, 16.2%; perianal fistula or abscess, 29.7%; furuncle, 15.3%; no local involvement before diagnosis, 39.8%. Multiple conditions were recorded in 32.4% of patients. None of the patients analyzed had a urinary catheter before diagnosis.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The sites involved on admission were as follows: scrotum, 54.05%; perineum, 37.83%; perianal area, 30%; penis, 27.02%; suprapubic area, 16%; and hypogastrium, 5.4%. All patients had some degree of edema on the penis or scrotum, 75.6% had fever, 71.4% had erythema, and 46% had necrotic areas (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Once diagnosis had been confirmed by the presence of symptoms and the results of imaging tests, all patients required at least 1 surgical intervention, and 32.4% had to be admitted to the ICU because of severe sepsis or septic shock. The mean stay in the ICU was 7.83 (6.6) days (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Only chronic alcoholism had a statistically significant association with ICU stay (<span class="elsevierStyleItalic">P</span><.001). The other underlying diseases (diabetes mellitus, ischemic heart disease, multiple conditions) were not associated with admission to the ICU.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Patients were transferred to the ward after leaving the ICU. The mean hospital stay was 27.54 (19.3) days. When diseases were classified independently, we observed that ischemic heart disease was significantly associated with a longer hospital stay (<span class="elsevierStyleItalic">P</span>=.007).</p><p id="par0125" class="elsevierStylePara elsevierViewall">Once infection had been controlled and the surgical wound had healed, 32.4% of patients required surgical reconstruction. Secondary sutures were applied in 13.5% of cases, skin flaps in 5.4%, and grafts in 13.5% (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">Based on available financial data and our results, we conclude that the mean overall health care cost of a patient with Fournier gangrene admitted to the ICU and requiring at least 1 surgical procedure, in addition to the procedure performed on admission (also included in the cost), is €25<span class="elsevierStyleHsp" style=""></span>108.67 (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">Infection was monomicrobial in 40.5% of patients and polymicrobial in 59.5%. The most commonly isolated microorganism was <span class="elsevierStyleItalic">Escherichia coli</span> (67.6%) followed by <span class="elsevierStyleItalic">Bacteroides fragilis</span> (21.4%). Other less commonly isolated agents were <span class="elsevierStyleItalic">Enterococcus faecium</span> (15.4%), <span class="elsevierStyleItalic">Pseudomonas anaerobius</span> (14.9%), <span class="elsevierStyleItalic">Mycobacterium morganii</span> (9.7%), <span class="elsevierStyleItalic">Enterococcus faecalis</span> (8.5%), and coagulase-negative staphylococci (6.7%).</p><p id="par0140" class="elsevierStylePara elsevierViewall">The routine empirical antibiotic treatment administered in patients diagnosed up to 2006 was metronidazole (500<span class="elsevierStyleHsp" style=""></span>mg/8<span class="elsevierStyleHsp" style=""></span>h), together with cefotaxime (2<span class="elsevierStyleHsp" style=""></span>g/d) and gentamicin adjusted for weight and renal function. From 2006 onwards, other regimens, such as meropenem 1<span class="elsevierStyleHsp" style=""></span>g/8<span class="elsevierStyleHsp" style=""></span>h, together with metronidazole 500<span class="elsevierStyleHsp" style=""></span>mg/8<span class="elsevierStyleHsp" style=""></span>h, were prescribed.</p><p id="par0145" class="elsevierStylePara elsevierViewall">Only 5 patients (13.50%) died of the infection; differences in age between those who survived (69.6 years) and those who died (55.8 years) were statistically significant (<span class="elsevierStyleItalic">P</span><.05). The origin of the infection was perianal abscess or fistula in 2 of the 5 patients who died; in the remaining 3 patients, no local primary cause was identified.</p><p id="par0150" class="elsevierStylePara elsevierViewall">A significant association was detected between the presence of multiple conditions in 1 patient and mortality (<span class="elsevierStyleItalic">P</span>=.015). Similarly, when the diseases analyzed were classified separately, we only observed a significant association between ischemic heart disease and death due to Fournier gangrene (<span class="elsevierStyleItalic">P</span>=.002) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0155" class="elsevierStylePara elsevierViewall">When Fournier gangrene was first described, it was thought to affect men only. However, today we know that it can occur in up to 10% of women. In a series of 39 women diagnosed with Fournier gangrene, Sorensen et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> observed that mean age, race, prevalence of comorbid conditions, and number of debridements were similar to those of men. However, twice as many women required mechanical ventilation and dialysis, and hospital stay was longer and mortality greater than in men, although none of these findings was statistically significant. We recorded no cases in women or children in our series.</p><p id="par0160" class="elsevierStylePara elsevierViewall">Common predisposing factors for Fournier gangrene include chronic alcoholism, systemic disorders, diabetes mellitus, chronic renal insufficiency, malignant neoplasm, and human immunodeficiency virus infection<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,14</span></a>; some series have reported an association between predisposing factors and mortality.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,15,16</span></a> These conditions are associated with reduced cell-mediated immune response, which favors infection. Most authors consider diabetes mellitus to be a risk factor for Fournier gangrene, although there is no agreement on whether it is associated with greater mortality.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Erol et al.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and Yanar et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> found that diabetes did not affect clinical outcome. In our study, 43.2% of patients had diabetes. We observed a statistically significant association between multiple conditions and mortality; however, of all the conditions analyzed only the association between ischemic heart disease and mortality was statistically significant. Ischemic heart disease was also associated with longer hospital stay.</p><p id="par0165" class="elsevierStylePara elsevierViewall">There is no consensus on the variables that predict poor outcome in patients with Fournier gangrene. Some studies show that early and extensive debridement can significantly reduce mortality and that involvement of large areas is associated with greater mortality, since more interventions are necessary.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> In contrast, other studies suggest that the degree of involvement and the number of debridements are not predictors of outcome.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Laor et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> developed the Fournier Gangrene Severity Index to determine the degree of severity and prognosis of the disease according to parameters such as temperature, heart rate, respiratory rate, hematocrit, leukocyte count, and serum levels of sodium, potassium, bicarbonate, and creatinine. The authors reported that a score of over 9 was associated with a 75% probability of death, whereas a score of 9 or less was associated with a probability of survival of 78%; both cutoff values have been validated elsewhere.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,19</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">It is important to recognize Fournier gangrene in the early stages, when cutaneous manifestations are minimal. However, diagnosis is difficult. Consequently, the condition is not recognized until an advanced stage (necrosis can spread at up to 2–3<span class="elsevierStyleHsp" style=""></span>cm/h) and other types of necrotizing fasciitis may be classed as Fournier gangrene, despite affecting areas other than the perineum.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Initial diagnosis is basically clinical, although, as with any type of necrotizing fasciitis, the histopathologic characteristics of Fournier gangrene (e.g., necrosis and suppuration of subcutaneous tissue, arteries, veins, superficial and deep fascia, and muscle) can also be determined.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">The first 24–48<span class="elsevierStyleHsp" style=""></span>hours are characterized by nonspecific symptoms associated with hardening of the perineal area, mild fever, and erythema of the affected tissue. If the condition is not diagnosed in the early stages and the process follows its normal course, hemorrhagic blisters appear and can quickly become necrotic. Given the anatomical continuity between the fasciae, necrosis can spread to distant sites. Furthermore, the patient's general condition worsens, with progression to septic shock in almost 50% of cases.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">The results of imaging tests are sometimes useful for confirming the clinical suspicion, determining the extension of the disease, and evaluating the response to treatment.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Radiography is more sensitive than physical examination for detection of subcutaneous emphysema in up to 89% of patients and reveals the pattern sometimes referred to as honeycomb scrotum.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22,23</span></a> Some authors consider ultrasound to be the imaging technique of choice when diagnosis cannot be confirmed by clinical history and physical examination.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Ultrasound makes it possible to identify gas in soft tissue, assess vascular flow in the testicles, and highlight subcutaneous edema and fluid collections.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Furthermore, it can be performed at the bedside. This is an important advantage, given that some patients are hospitalized in the ICU or may be hemodynamically unstable, thus making it difficult to move them to the radiology department for a computed tomography (CT) scan. CT imaging does not usually show scrotal structures as well as ultrasound and often requires injection of contrast medium, which may not always be possible, as patients with Fournier gangrene often have renal failure.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23,25</span></a> Nonetheless, some publications consider CT to be the procedure of choice since it enables evaluation of the extent of subcutaneous emphysema and fluid collections in soft tissue.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Fournier gangrene is usually considered a polymicrobial infection, although not all the microorganisms involved are necessarily detected in culture. Both aerobes and anaerobes are almost always present, although anaerobes are isolated less frequently.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The most commonly isolated species are <span class="elsevierStyleItalic">E. coli</span>, followed by streptococci, staphylococci, <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>, <span class="elsevierStyleItalic">Bacteroides</span> species, and clostridia. These entities are present in normal gastrointestinal and perineal flora.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,18,25</span></a> We isolated <span class="elsevierStyleItalic">E. coli</span> in 67.6% of patients, followed by <span class="elsevierStyleItalic">B. fragilis</span> in 21.4%.</p><p id="par0195" class="elsevierStylePara elsevierViewall">The largest series to date (1726 cases) was published by Eke,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> who reported that the likely source of infection was the skin in 24% of cases, colon and rectum in 21%, and urinary tract in 19%. The source was unknown in 36% of patients.</p><p id="par0200" class="elsevierStylePara elsevierViewall">The mortality rate of Fournier gangrene can be as high as 67%,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> despite new techniques applied in the ICU, extensive debridement, wound care, and broad-spectrum antibiotics. According to the literature, treatment is based on early and extensive debridement to remove infected and necrotic tissue, hemodynamic stabilization, and broad-spectrum antibiotics.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,26</span></a> The antibiotic regimen varies depending on the center and resistance to specific antibiotics in the geographic area where the microorganisms are isolated. Recent studies recommend starting empirical therapy with third-generation cephalosporins for gram-negative agents and metronidazole for anaerobes, with the possibility of adding aminoglycosides.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4,21</span></a> An equally effective and easier alternative is monotherapy with broad-spectrum β-lactams or carbapenems of the ureidopenicillin family (piperacillin-tazobactam).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> At our center, we initially used 3 antibiotics: a third-generation cephalosporin, metronidazole, and, renal function permitting, gentamicin. Antibiotic resistance and the advent of agents with a broader spectrum, which are also easier to use, have led us to prescribe empirical carbapenems in monotherapy or combined with metronidazole, as this approach is effective in most patients.</p><p id="par0205" class="elsevierStylePara elsevierViewall">Reconstructive procedures were necessary in 32.5% of the patients in our series. Of those who required a flap, 5.4% received vascularized musculocutaneous or fascial pedicle flaps. When it was necessary to use grafts, we chose thick grafts owing to their reduced contractility.</p><p id="par0210" class="elsevierStylePara elsevierViewall">Fournier gangrene is a urological emergency with high mortality (20%–30%) despite early and appropriate treatment. There is no consensus on predictors of the disease. In most cases, the anorectal or genitourinary area is affected. When involvement of these sites occurs with underlying systemic diseases, such as diabetes mellitus and chronic alcoholism, susceptibility to polymicrobial infection increases. Although its incidence is low, Fournier gangrene generates high health care costs; therefore, primary and secondary preventive measures should be applied to correct the risk factors associated with the primary infection.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of Interest</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres95619" "titulo" => array:5 [ 0 => "Abstract" 1 => "Background and Objectives" 2 => "Material and Methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec82778" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres95618" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusión" ] ] 3 => array:2 [ "identificador" => "xpalclavsec82777" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of Interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-01-18" "fechaAceptado" => "2011-04-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec82778" "palabras" => array:3 [ 0 => "Fournier gangrene" 1 => "Necrotizing fasciitis" 2 => "Health costs" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec82777" "palabras" => array:3 [ 0 => "Gangrena de Fournier" 1 => "Fascitis necrotizante" 2 => "Coste sanitario" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle">Background and Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Fournier gangrene is a urological emergency associated with a high mortality. It is a necrotizing fasciitis caused by polymicrobial infection originating in the anorectal or genitourinary area. The aim of this study was to analyze the epidemiological and clinical characteristics of Fournier gangrene along with the variables that influence disease course and mortality in patients treated in our department.</p> <span class="elsevierStyleSectionTitle">Material and Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We carried out a retrospective study of 37 patients diagnosed with Fournier gangrene between January 2001 and October 2010.</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">All the patients were men, 43.2% had diabetes, and the mean age of the patients was 57.68 years. Statistically significant differences were observed between the age of surviving patients and that of patients who died (55.8 and 69.6 years, respectively). The mean hospital stay was 27.54 days and 32.4% of patients required admission to the intensive care unit. Etiology was unknown in 39.8% of cases. Polymicrobial infection was observed in 59.5% of cases. The mean health care cost associated with a patient diagnosed with Fournier gangrene admitted to intensive care and requiring at least 1 procedure in the operating room was €25<span class="elsevierStyleHsp" style=""></span>108.67. Mortality was 13.5%. Based on analysis of individual comorbid conditions, only ischemic heart disease displayed a statistically significant association with mortality due to Fournier gangrene; ischemic heart disease was also associated with longer hospital stay.</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Fournier gangrene is associated with high mortality despite appropriate early treatment. Although the condition is infrequent, the high associated health care costs suggest that primary and secondary prevention measures should be implemented.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La gangrena de Fournier es una urgencia urológica definida como una fascitis necrotizante, con una alta mortalidad, resultado de una infección polimicrobiana que se origina en la región anorrectal y/o genitourinaria. El objetivo de este estudio es analizar las características epidemiológicas y clínicas, así como las variables que han influido en la evolución y mortalidad de los pacientes tratados en nuestro Servicio.</p> <span class="elsevierStyleSectionTitle">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El estudio analiza retrospectivamente 37 pacientes diagnosticados de gangrena de Fournier en el periodo de tiempo comprendido entre enero del 2001 a octubre de 2010.</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Todos los pacientes son hombres, con una edad media de 57,68 años, existiendo diferencias estadísticas en la edad de los fallecidos respecto a los que sobreviven, 69,6 años frente a 55,8 años. El 43,2% eran diabéticos. La estancia media hospitalaria fue de 27,54 días. El 32,4% precisó de ingreso en la UCI. En el 39,8% se desconoce su etiología. La infección fue polimicrobiana en el 59,5% de los casos. El coste sanitario medio de un paciente diagnosticado de gangrena de Fournier que ingresa en la Unidad de Cuidados Intensivos (UCI) y requiere de al menos una cura en quirófano es de 25.108,67 euros. La mortalidad fue del 13,5%. Al estratificar las patologías estudiadas de forma independiente se observa que sólo la cardiopatía isquémica se relacionó de forma significativa con la mortalidad y una mayor estancia hospitalaria.</p> <span class="elsevierStyleSectionTitle">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La gangrena de Fournier es una patología con una alta mortalidad, a pesar de un tratamiento adecuado precoz. Es una patología con una baja incidencia, pero supone un coste elevado para el sistema sanitario, por lo que serían necesarias medidas de prevención primaria y secundaria.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Jiménez-Pacheco A, et al. Análisis descriptivo y coste económico-sanitario de nuestra serie de 37 casos. Actas Dermosifiliogr. 2012;103:29–35.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1003 "Ancho" => 750 "Tamanyo" => 123890 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Characteristic necrotic plaques and blisters.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 750 "Ancho" => 1000 "Tamanyo" => 166092 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Exposure of the penis and testicles after extensive debridement. Healthy tissue is visible.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 878 "Ancho" => 750 "Tamanyo" => 145266 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Reconstruction of the genital area and covering with skin after debridement.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "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"><td 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" style="border-bottom: 2px solid black">Product Unit \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Unit Cost \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Mean Hospital Stay and Time in the Operating Room \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Amount \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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">Stay in the ICU \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">€1609.65/d \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.83<span class="elsevierStyleHsp" style=""></span>d \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">€12<span class="elsevierStyleHsp" style=""></span>603.65 (1609.65<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>7.83) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stay on the urology ward \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">€373.82/d \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27.50<span class="elsevierStyleHsp" style=""></span>d \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">€10<span class="elsevierStyleHsp" style=""></span>295 (373.82<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>27.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use of an operating room with 1 surgeon \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">€884.05/d \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.50<span class="elsevierStyleHsp" style=""></span>h \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">€2210.12 (884.05<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">€25<span class="elsevierStyleHsp" style=""></span>108.67 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab181979.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Calculation of the Mean Overall Health Care Cost Generated by a Patient With Fournier Gangrene Admitted to the Intensive Care Unit (ICU) and Requiring 2 Procedures in the Operating Room.</p>" ] ] 4 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "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"><td 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">Study Variables \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No. of Patients</td><td 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">Association With Stay in ICU<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td 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">Association With Mean Hospital Stay \t\t\t\t\t\t\n \t\t\t\t</td><td 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">Association With Mortality \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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">Alcoholism \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (<span class="elsevierStyleItalic">P</span>=.000) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 (<span class="elsevierStyleItalic">P</span>=.760) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 (<span class="elsevierStyleItalic">P</span>=.283) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diabetes mellitus \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (<span class="elsevierStyleItalic">P</span>=.399) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 (<span class="elsevierStyleItalic">P</span>=.357) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (<span class="elsevierStyleItalic">P</span>=.875) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ischemic heart disease \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (<span class="elsevierStyleItalic">P</span>=.376) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 (<span class="elsevierStyleItalic">P</span>=.007) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (<span class="elsevierStyleItalic">P</span>=.002) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Multiple conditions \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (<span class="elsevierStyleItalic">P</span>=.114) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 (<span class="elsevierStyleItalic">P</span>=.002) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (<span class="elsevierStyleItalic">P</span>=.015) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Perianal fistula/abscess \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (<span class="elsevierStyleItalic">P</span>=.740) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 (<span class="elsevierStyleItalic">P</span>=.444) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (<span class="elsevierStyleItalic">P</span>=.589) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Urethral stricture \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (<span class="elsevierStyleItalic">P</span>=.315) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 (<span class="elsevierStyleItalic">P</span>=.791) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (<span class="elsevierStyleItalic">P</span>=.290) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Previous catheter \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Subsequent catheter \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (<span class="elsevierStyleItalic">P</span>=.311) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 (<span class="elsevierStyleItalic">P</span>=.395) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Admission to ICU \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 (<span class="elsevierStyleItalic">P</span>=.993) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (<span class="elsevierStyleItalic">P</span>=.157) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Monomicrobial infection \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (<span class="elsevierStyleItalic">P</span>=.536) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 (<span class="elsevierStyleItalic">P</span>=.698) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (<span class="elsevierStyleItalic">P</span>=.959) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Polymicrobial infection \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (<span class="elsevierStyleItalic">P</span>=.003) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 (<span class="elsevierStyleItalic">P</span>=.698) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (<span class="elsevierStyleItalic">P</span>=.678) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Secondary suture \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 (<span class="elsevierStyleItalic">P</span>=.049) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46 (<span class="elsevierStyleItalic">P</span>=.000) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reconstruction with skin flap \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (<span class="elsevierStyleItalic">P</span>=.855) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 (<span class="elsevierStyleItalic">P</span>=.002) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reconstruction with skin graft \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 (<span class="elsevierStyleItalic">P</span>=.008) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">58 (<span class="elsevierStyleItalic">P</span>=.000) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Death \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (<span class="elsevierStyleItalic">P</span>=.157) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (<span class="elsevierStyleItalic">P</span>=.009) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab181978.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara">The association with stay in the intensive care unit or the hospital is measured in days.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Association Between Study Variables and Admission to the Intensive Care Unit (ICU), Mean Hospital Stay, and Mortality.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:26 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Gangrena de Fournier: Estudio retrospectivo de 41 casos" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 17 | 8 | 25 |
| 2024 October | 147 | 47 | 194 |
| 2024 September | 217 | 37 | 254 |
| 2024 August | 230 | 79 | 309 |
| 2024 July | 234 | 39 | 273 |
| 2024 June | 235 | 38 | 273 |
| 2024 May | 198 | 48 | 246 |
| 2024 April | 205 | 24 | 229 |
| 2024 March | 250 | 29 | 279 |
| 2024 February | 340 | 34 | 374 |
| 2024 January | 412 | 42 | 454 |
| 2023 December | 663 | 16 | 679 |
| 2023 November | 532 | 25 | 557 |
| 2023 October | 448 | 24 | 472 |
| 2023 September | 681 | 35 | 716 |
| 2023 August | 675 | 26 | 701 |
| 2023 July | 442 | 36 | 478 |
| 2023 June | 314 | 20 | 334 |
| 2023 May | 435 | 31 | 466 |
| 2023 April | 258 | 29 | 287 |
| 2023 March | 191 | 26 | 217 |
| 2023 February | 158 | 20 | 178 |
| 2023 January | 101 | 29 | 130 |
| 2022 December | 57 | 54 | 111 |
| 2022 November | 36 | 26 | 62 |
| 2022 October | 27 | 24 | 51 |
| 2022 September | 21 | 39 | 60 |
| 2022 August | 25 | 31 | 56 |
| 2022 July | 26 | 29 | 55 |
| 2022 June | 26 | 26 | 52 |
| 2022 May | 77 | 31 | 108 |
| 2022 April | 138 | 35 | 173 |
| 2022 March | 126 | 52 | 178 |
| 2022 February | 162 | 40 | 202 |
| 2022 January | 140 | 43 | 183 |
| 2021 December | 101 | 48 | 149 |
| 2021 November | 90 | 50 | 140 |
| 2021 October | 108 | 64 | 172 |
| 2021 September | 96 | 57 | 153 |
| 2021 August | 141 | 46 | 187 |
| 2021 July | 127 | 51 | 178 |
| 2021 June | 114 | 31 | 145 |
| 2021 May | 133 | 57 | 190 |
| 2021 April | 345 | 96 | 441 |
| 2021 March | 326 | 56 | 382 |
| 2021 February | 241 | 41 | 282 |
| 2021 January | 146 | 42 | 188 |
| 2020 December | 182 | 25 | 207 |
| 2020 November | 112 | 33 | 145 |
| 2020 October | 87 | 20 | 107 |
| 2020 September | 98 | 23 | 121 |
| 2020 August | 155 | 47 | 202 |
| 2020 July | 168 | 41 | 209 |
| 2020 June | 146 | 33 | 179 |
| 2020 May | 164 | 33 | 197 |
| 2020 April | 137 | 34 | 171 |
| 2020 March | 74 | 30 | 104 |
| 2020 February | 2 | 7 | 9 |
| 2020 January | 4 | 2 | 6 |
| 2019 December | 4 | 5 | 9 |
| 2019 November | 4 | 6 | 10 |
| 2019 October | 1 | 0 | 1 |
| 2019 September | 0 | 1 | 1 |
| 2019 August | 6 | 4 | 10 |
| 2019 July | 4 | 4 | 8 |
| 2019 June | 4 | 7 | 11 |
| 2019 May | 4 | 12 | 16 |
| 2019 April | 2 | 9 | 11 |
| 2019 March | 2 | 8 | 10 |
| 2019 February | 0 | 1 | 1 |
| 2019 January | 2 | 4 | 6 |
| 2018 December | 2 | 0 | 2 |
| 2018 October | 4 | 0 | 4 |
| 2018 September | 1 | 0 | 1 |
| 2018 March | 2 | 2 | 4 |
| 2018 February | 34 | 6 | 40 |
| 2018 January | 63 | 13 | 76 |
| 2017 December | 66 | 6 | 72 |
| 2017 November | 74 | 10 | 84 |
| 2017 October | 58 | 4 | 62 |
| 2017 September | 55 | 11 | 66 |
| 2017 August | 94 | 15 | 109 |
| 2017 July | 83 | 2 | 85 |
| 2017 June | 88 | 21 | 109 |
| 2017 May | 86 | 10 | 96 |
| 2017 April | 100 | 10 | 110 |
| 2017 March | 106 | 42 | 148 |
| 2017 February | 89 | 15 | 104 |
| 2017 January | 79 | 6 | 85 |
| 2016 December | 90 | 8 | 98 |
| 2016 November | 108 | 13 | 121 |
| 2016 October | 116 | 22 | 138 |
| 2016 September | 95 | 5 | 100 |
| 2016 August | 85 | 10 | 95 |
| 2016 July | 71 | 20 | 91 |
| 2016 June | 13 | 14 | 27 |
| 2016 May | 9 | 0 | 9 |
| 2016 April | 10 | 16 | 26 |
| 2016 March | 9 | 2 | 11 |
| 2016 February | 11 | 2 | 13 |
| 2016 January | 9 | 1 | 10 |
| 2015 December | 4 | 0 | 4 |
| 2015 November | 22 | 3 | 25 |
| 2015 October | 21 | 5 | 26 |
| 2015 September | 15 | 1 | 16 |
| 2015 August | 14 | 1 | 15 |
| 2015 July | 88 | 12 | 100 |
| 2015 June | 57 | 7 | 64 |
| 2015 May | 127 | 12 | 139 |
| 2015 April | 77 | 12 | 89 |
| 2015 March | 81 | 11 | 92 |
| 2015 February | 64 | 12 | 76 |
| 2015 January | 104 | 11 | 115 |
| 2014 December | 114 | 5 | 119 |
| 2014 November | 76 | 8 | 84 |
| 2014 October | 77 | 20 | 97 |
| 2014 September | 73 | 8 | 81 |
| 2014 August | 82 | 19 | 101 |
| 2014 July | 96 | 16 | 112 |
| 2014 June | 131 | 15 | 146 |
| 2014 May | 133 | 17 | 150 |
| 2014 April | 100 | 12 | 112 |
| 2014 March | 94 | 23 | 117 |
| 2014 February | 79 | 21 | 100 |
| 2014 January | 85 | 20 | 105 |
| 2013 December | 45 | 9 | 54 |
| 2013 November | 25 | 8 | 33 |
| 2013 October | 28 | 8 | 36 |
| 2013 September | 15 | 7 | 22 |
| 2013 August | 17 | 21 | 38 |
| 2013 July | 16 | 14 | 30 |
| 2013 June | 15 | 21 | 36 |
| 2013 May | 17 | 16 | 33 |
| 2013 April | 17 | 18 | 35 |
| 2013 March | 15 | 16 | 31 |
| 2013 February | 153 | 4 | 157 |
| 2013 January | 62 | 8 | 70 |
| 2012 December | 25 | 9 | 34 |
| 2012 November | 4 | 3 | 7 |
| 2012 October | 3 | 7 | 10 |
| 2012 September | 0 | 3 | 3 |
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