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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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"apellidos" => "Zuluaga-Gómez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Urología, Hospital Universitario San Cecilio, Granada, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario San Cecilio, Granada, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Gangrena de Fournier. 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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 7 | 4 | 11 |
| 2024 Octubre | 147 | 47 | 194 |
| 2024 Septiembre | 217 | 37 | 254 |
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| 2024 Enero | 412 | 42 | 454 |
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| 2023 Noviembre | 532 | 25 | 557 |
| 2023 Octubre | 448 | 24 | 472 |
| 2023 Septiembre | 681 | 35 | 716 |
| 2023 Agosto | 675 | 26 | 701 |
| 2023 Julio | 442 | 36 | 478 |
| 2023 Junio | 314 | 20 | 334 |
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| 2023 Abril | 258 | 29 | 287 |
| 2023 Marzo | 191 | 26 | 217 |
| 2023 Febrero | 158 | 20 | 178 |
| 2023 Enero | 101 | 29 | 130 |
| 2022 Diciembre | 57 | 54 | 111 |
| 2022 Noviembre | 36 | 26 | 62 |
| 2022 Octubre | 27 | 24 | 51 |
| 2022 Septiembre | 21 | 39 | 60 |
| 2022 Agosto | 25 | 31 | 56 |
| 2022 Julio | 26 | 29 | 55 |
| 2022 Junio | 26 | 26 | 52 |
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| 2022 Abril | 138 | 35 | 173 |
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| 2022 Febrero | 162 | 40 | 202 |
| 2022 Enero | 140 | 43 | 183 |
| 2021 Diciembre | 101 | 48 | 149 |
| 2021 Noviembre | 90 | 50 | 140 |
| 2021 Octubre | 108 | 64 | 172 |
| 2021 Septiembre | 96 | 57 | 153 |
| 2021 Agosto | 141 | 46 | 187 |
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| 2021 Junio | 114 | 31 | 145 |
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| 2021 Abril | 345 | 96 | 441 |
| 2021 Marzo | 326 | 56 | 382 |
| 2021 Febrero | 241 | 41 | 282 |
| 2021 Enero | 146 | 42 | 188 |
| 2020 Diciembre | 182 | 25 | 207 |
| 2020 Noviembre | 112 | 33 | 145 |
| 2020 Octubre | 87 | 20 | 107 |
| 2020 Septiembre | 98 | 23 | 121 |
| 2020 Agosto | 155 | 47 | 202 |
| 2020 Julio | 168 | 41 | 209 |
| 2020 Junio | 146 | 33 | 179 |
| 2020 Mayo | 164 | 33 | 197 |
| 2020 Abril | 137 | 34 | 171 |
| 2020 Marzo | 74 | 30 | 104 |
| 2020 Febrero | 2 | 7 | 9 |
| 2020 Enero | 4 | 2 | 6 |
| 2019 Diciembre | 4 | 5 | 9 |
| 2019 Noviembre | 4 | 6 | 10 |
| 2019 Octubre | 1 | 0 | 1 |
| 2019 Septiembre | 0 | 1 | 1 |
| 2019 Agosto | 6 | 4 | 10 |
| 2019 Julio | 4 | 4 | 8 |
| 2019 Junio | 4 | 7 | 11 |
| 2019 Mayo | 4 | 12 | 16 |
| 2019 Abril | 2 | 9 | 11 |
| 2019 Marzo | 2 | 8 | 10 |
| 2019 Febrero | 0 | 1 | 1 |
| 2019 Enero | 2 | 4 | 6 |
| 2018 Diciembre | 2 | 0 | 2 |
| 2018 Octubre | 4 | 0 | 4 |
| 2018 Septiembre | 1 | 0 | 1 |
| 2018 Marzo | 2 | 2 | 4 |
| 2018 Febrero | 34 | 6 | 40 |
| 2018 Enero | 63 | 13 | 76 |
| 2017 Diciembre | 66 | 6 | 72 |
| 2017 Noviembre | 74 | 10 | 84 |
| 2017 Octubre | 58 | 4 | 62 |
| 2017 Septiembre | 55 | 11 | 66 |
| 2017 Agosto | 94 | 15 | 109 |
| 2017 Julio | 83 | 2 | 85 |
| 2017 Junio | 88 | 21 | 109 |
| 2017 Mayo | 86 | 10 | 96 |
| 2017 Abril | 100 | 10 | 110 |
| 2017 Marzo | 106 | 42 | 148 |
| 2017 Febrero | 89 | 15 | 104 |
| 2017 Enero | 79 | 6 | 85 |
| 2016 Diciembre | 90 | 8 | 98 |
| 2016 Noviembre | 108 | 13 | 121 |
| 2016 Octubre | 116 | 22 | 138 |
| 2016 Septiembre | 95 | 5 | 100 |
| 2016 Agosto | 85 | 10 | 95 |
| 2016 Julio | 71 | 20 | 91 |
| 2016 Junio | 13 | 14 | 27 |
| 2016 Mayo | 9 | 0 | 9 |
| 2016 Abril | 10 | 16 | 26 |
| 2016 Marzo | 9 | 2 | 11 |
| 2016 Febrero | 11 | 2 | 13 |
| 2016 Enero | 9 | 1 | 10 |
| 2015 Diciembre | 4 | 0 | 4 |
| 2015 Noviembre | 22 | 3 | 25 |
| 2015 Octubre | 21 | 5 | 26 |
| 2015 Septiembre | 15 | 1 | 16 |
| 2015 Agosto | 14 | 1 | 15 |
| 2015 Julio | 88 | 12 | 100 |
| 2015 Junio | 57 | 7 | 64 |
| 2015 Mayo | 127 | 12 | 139 |
| 2015 Abril | 77 | 12 | 89 |
| 2015 Marzo | 81 | 11 | 92 |
| 2015 Febrero | 64 | 12 | 76 |
| 2015 Enero | 104 | 11 | 115 |
| 2014 Diciembre | 114 | 5 | 119 |
| 2014 Noviembre | 76 | 8 | 84 |
| 2014 Octubre | 77 | 20 | 97 |
| 2014 Septiembre | 73 | 8 | 81 |
| 2014 Agosto | 82 | 19 | 101 |
| 2014 Julio | 96 | 16 | 112 |
| 2014 Junio | 131 | 15 | 146 |
| 2014 Mayo | 133 | 17 | 150 |
| 2014 Abril | 100 | 12 | 112 |
| 2014 Marzo | 94 | 23 | 117 |
| 2014 Febrero | 79 | 21 | 100 |
| 2014 Enero | 85 | 20 | 105 |
| 2013 Diciembre | 45 | 9 | 54 |
| 2013 Noviembre | 25 | 8 | 33 |
| 2013 Octubre | 28 | 8 | 36 |
| 2013 Septiembre | 15 | 7 | 22 |
| 2013 Agosto | 17 | 21 | 38 |
| 2013 Julio | 16 | 14 | 30 |
| 2013 Junio | 15 | 21 | 36 |
| 2013 Mayo | 17 | 16 | 33 |
| 2013 Abril | 17 | 18 | 35 |
| 2013 Marzo | 15 | 16 | 31 |
| 2013 Febrero | 153 | 4 | 157 |
| 2013 Enero | 62 | 8 | 70 |
| 2012 Diciembre | 25 | 9 | 34 |
| 2012 Noviembre | 4 | 3 | 7 |
| 2012 Octubre | 3 | 7 | 10 |
| 2012 Septiembre | 0 | 3 | 3 |
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