Factores predictivos de colecistitis aguda gangrenosa / Predictive factors of acute gangrenous cholecystitis

Introducción: La colecistitis aguda gangrenosa (CAG) es una complicación severa de la colecistitis aguda, afectando entre el 2 y 20% de las mismas. En la actualidad no hay disponibles guías definidas para detectar estos casos y definir su conducta quirúrgica con rapidez. El objetivo de este trabajo es contribuir al estudio de los factores predictivos de la CAG para identificar los pacientes que requieren cirugía de urgencia. Material y métodos: Se realizó una búsqueda retrospectiva de pacientes que fueron sometidos a colecistectomía con diagnóstico preoperatorio de colecistitis aguda en el Nuevo Hospital San Roque, entre enero de 2011 y diciembre de 2012. El Nuevo Hospital San Roque es un centro público de atención de tercer nivel al que acceden de forma gratuita los habitantes de la Ciudad de Córdoba (Argentina) y alrededores que no cuentan con cobertura de salud privada. Los factores de riesgo preoperatorios evaluados incluyeron sexo, edad, diabetes, obesidad, vómitos, fiebre, recuento de glóbulos blancos, eritrosedimentación, enzimas hepáticas, amilasa y hallazgos ecográficos como diámetro de la pared vesicular y líquido perivesicular. Los pacientes fueron divididos en 2 grupos de acuerdo con el diagnóstico anatomopatológico: el grupo 1 incluyó pacientes con CAG y el grupo 2, pacientes con colecistitis aguda no gangrenosa. Resultados: De un total de 183 pacientes sometidos a colecistectomía, 101 (55,1%) presentaron CAG. El análisis multivariado determinó que en nuestro grupo de estudio la razón de probabilidades de CAG asociadas a las variables fiebre, diabetes, y sexo masculino son mayores de 2 y estadísticamente significativas. Asimismo, la razón de probabilidades de CAG aumenta con el nivel de glóbulos blancos y eritrosedimentación. Conclusión: Las variables fiebre, diabetes, sexo masculino, glóbulos blancos, y eritrosedimentación pueden ser consideradas factores predictivos independientes en nuestro caso de estudio.

Introduction: Acute gangrenous cholecystitis (AGC) is a severe complication of acute cholecystitis affecting between 2 and 20% of them. To date, there are no defined guidelines available to triage high-risk surgical patients. Our objective is to contribute to the literature studying predictive factors of AGC aimed at identifying patients who require emergency surgery. Materials and methods: We conducted a retrospective search of patients who underwent cholecystectomies with preoperative diagnosis of acute cholecystitis at Nuevo Hospital San Roque between January 2011 and December 2012. Nuevo Hospital San Roque is a public hospital in Argentina that provides health services to non-privately insured residents of the Cordoba metropolitan area. The resulting sample was used to perform a multivariate analysis encompassing the following preoperative risk factors: gender, age, diabetes, obesity, vomiting, fever, white blood cell count, erythrocyte sedimentation rate, liver enzymes, amylase and sonographic findings like diameter of gallbladder wall and perivesicular liquid. Patients were divided into two groups according to pathological diagnosis: group 1 included patients with acute AGC and group 2 with no gangrenous acute cholecystitis. Results: One hundred and one patients presented AGC out of a total of 183 patients analyzed. Our multivariate analysis determined that the odds ratio of CAG associated with the variables fever, diabetes, and male gender are greater than 2 and statistically significant. Likewise, the odds ratio of CAG is increasing in the level of white blood cells and in the erythrocyte sedimentation rate. Conclusion: We found that fever, diabetes, male gender, white blood cells, and erythrocyte sedimentation rate can be considered independent predictors in our sample.

Unusual clustering of diseases and manifestations in pediatric admissions of a tertiary care center.

BACKGROUND: Cluster investigations has been an important tool in investigations of diseases. While clustering of diseases or a manifestation in community can cause great public alarm, similar unexplained clustering in hospital admissions has baffled clinicians. Objectives: (a) To determine whether perceived unexplained clustering of diseases and manifestations among hospital admissions is real or significant. (b) To look for possible explanations of such clustering. DESIGN: One-year prospective observational and two-year retrospective study. MATERIAL AND METHODS: Cases admitted under pediatric and neonatal services (excluding rooming in babies) from September 2002 to August 2003 formed material for prospective and cases admitted for 2 years prior for retrospective study. Whenever an unexplained cluster of disease/manifestation was perceived, case definition was finalized and cases recorded. Retrospective cluster analysis was done for some significant unexplained clusters detected prospectively. These clusters case rate were analyzed in relation to age, sex, climatic conditions, etiology of case, etc. to detect any correlation. Pearson correlation coefficient, chi-square test, centroid method and Z test of proportion were used for statistical significance. RESULTS: Eight unexplained clusters were perceived in prospective study. 3 (hyperbilirubinemia in exchange range hypocalcemic seizures and vesicoureteric reflux) proved statistically not significant. 3 were small clusters of uncommon diseases / manifestations (biliary atresia, cardiomyopathy, and acral gangrene). Two large significant clusters, major non-traumatic bleeding manifestations (MNTBM) and acute renal failure (ARF) occurred to which retrospective study was extended. Tmax and Tmin (average maximum and minimum daily temperature) had statistically significant positive correlation with ARF (gamma = + 0.83, P <0.001 for Tmax and gamma =+ 0.56, P = 0.002 for Tmin) and negative correlation with MNTBM (gamma = - 0.34, P = 0.040 for Tmax and gamma = - 0.59, P <0.001 for Tmin). Barometric pressure has significant negative and positive correlation with MNTBM and ARF respectively (gamma =+ 0.57, P <0.001 for MNTBM and gamma = -0.45,P = 0.006 for ARF). The clusters also had significant positive correlations with female sex and age under 1 year (Z = 2.48, P <0.001,chi2=13.83, P<0.001 for sex and age of MNTBM and Z =3.11, P <0.001, chi2 =10.85, P <0.001 forage and sex of ARF cases respectively). Three small clusters and a small subgroup of MNTBM(subcutaneous nodules as manifestations of bleeding disorders) occurred predominantly under one year and different sexes were involved. CONCLUSIONS: Several significant unexplained clustering were noted among hospital admissions. There was significant correlation with climatic conditions, age and sex. Larger, longer and multicentric studies in different geographical areas are required to investigate more plausible but complex biological phenomenon and associations related to diseases or manifestations. Cluster awareness has diagnostic and management implications for clinician as it also helps in early recognition of disease outbreak and dissemination of information and hospital staff to be prepared to handle increased number of cases and its treatment.