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There is an association between disease location and gestational age at birth in newborns submitted to surgery due to necrotizing enterocolitis
Existe associação entre a localização da doença e a idade gestacional ao nascimento de recém-nascidos operados por enterocolite necrosante
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Fraga" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Letícia" "apellidos" => "Feldens" "email" => array:1 [ 0 => "leticiafeldens@yahoo.com.br" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "João C.K. de" "apellidos" => "Souza" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "José C." "apellidos" => "Fraga" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Universidade Federal do Rio Grande do Sul (UFRGS), Programa de Pós-graduação em Medicina: Ciências Cirúrgicas, Porto Alegre, RS, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital da Criança Conceição, Porto Alegre, RS, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Existe associação entre a localização da doença e a idade gestacional ao nascimento de recém-nascidos operados por enterocolite necrosante" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1088 "Ancho" => 1653 "Tamanyo" => 82468 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Association between the site of involvement of necrotizing enterocolitis and gestational age, by group.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Necrotizing enterocolitis (NEC) is a disease that especially affects preterm infants and those with low birth weight (<2500<span class="elsevierStyleHsp" style=""></span>g).<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> Studies show the existence of an inverse association between mortality and birth weight.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">2</span></a> The incidence of NEC is variable, depending on the geographic area, ethnicity, and genetic and environmental factors; despite the improved care and improved survival of an increasing number of preterm infants, its incidence remains high in some countries.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> NEC is the most devastating gastrointestinal disease in neonates, occurring in 0.7 per 1000 patients, and in up to 7% of those hospitalized in neonatal intensive care units (NICUs), with a mortality ranging from 20% to 50%.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">4–6</span></a> There is still a controversy regarding the disease's etiology, pathophysiology, and the importance of all possible causal factors.</p><p id="par0010" class="elsevierStylePara elsevierViewall">During the 1980s, before the age of surfactant's and improved neonatal care, studies on NEC showed that the patients most severely affected by the disease were preterm infants between 33 and 35 weeks of gestation.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">7,8</span></a> However, more recent studies have shown a higher frequency of the disease in preterm infants born at 29–31 weeks of gestation.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In addition to the increasing survival of preterm infants, studies also show that the disease's etiology may differ between preterm and full-term infants. In the latter, the heart diseases and other conditions that predispose to intestinal ischemia seem to be more associated with the disease than the intestinal immaturity and greater permeability to the bacteria and food substrates observed in preterm infants.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Several studies have attempted to elucidate the etiology of NEC,<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">9,10</span></a> and others have investigated potential prevention and treatment strategies.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">11,12</span></a> Few studies have attempted to associate gestational age to the intestinal segment most affected by the disease. The present study sought to identify an association between disease location and the gestational age at birth in newborns submitted to surgery due to NEC.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">Newborns submitted to surgery due to NEC (historical cohort) at Hospital da Criança Conceição, Grupo Hospitalar Conceição, Porto Alegre, state of Rio Grande do Sul, Brazil, between November 1991 and December 2012 were evaluated. Inclusion criteria were the histological confirmation of NEC in patients submitted to laparotomy and resection of intestinal loops, such as ischemia, necrosis, or perforation, as well as the histological findings of coagulation necrosis, inflammation, tissue repair alterations, or the presence of intestinal pneumatosis in the anatomopathological examinations. Cases of single perforation associated with prematurity were excluded. Eligible patients were followed for 60 days regarding the outcomes of death, survival, and presence of complications associated with the disease and the surgery.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patients were divided into four categories according to gestational age: <30 weeks; 30–33 weeks and 6 days; 34–36 weeks and 6 days, and ≥37 weeks. Gestational age was measured according to the date of the last menstrual period, ultrasonography findings, and according to the methods of Ballard et al.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> (preterm infants <32 weeks) and Capurro et al.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Exploratory laparotomy was indicated in cases of pneumoperitoneum, deterioration of the clinical status after peritoneal cavity drainage, positive paracentesis (presence of stool or bacteria in the peritoneal fluid of patients with two relative indications of surgery), or presence of three or more relative indications of laparotomy.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> Relative indications were: fixed abdominal mass, clinical deterioration (hypotension, poor perfusion and skin pallor, respiratory function worsening, thermal instability, tachycardia, and worsening of laboratory tests), abdominal wall cellulitis, presence of a fixed abdominal loop in a series of abdominal X-rays, diffuse intestinal pneumatosis (present in the four quadrants), and air portogram.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Data were stratified according to gestational age and analyzed using the statistical software SPSS (IBM SPSS Statistics for Windows, version 19.0, NY, USA). Comparisons between groups were performed using the chi-squared test, Fisher's exact test, and analysis of variance (ANOVA). Tukey's post hoc test was utilized when ANOVA was used to evaluate the statistical difference between the groups. Spearman's coefficient was utilized to demonstrate the correlation between gestational age and the most affected intestinal segment. A <span class="elsevierStyleItalic">p</span>-value <0.05 was considered significant.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The study was approved by the Research Ethics Committee of the institution (study number 09/079), and was carried out according to the rules of the Declaration of Helsinki. Informed consent was obtained from the patients’ parents or guardians prior to surgery.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">A total of 198 newborns submitted to laparotomy due to NEC, with a median gestational age of 32 weeks (24–42), were evaluated. The NICU where the study was performed receives on average 670 patients a year, with an incidence of NEC ranging from 2.7% to 4.3% in the study years, requiring surgical treatment in 27% to 50% of patients.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Birth weight showed a mean of 1535<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>697<span class="elsevierStyleHsp" style=""></span>g (range: 555–4160<span class="elsevierStyleHsp" style=""></span>g). The patients were distributed according to the gestational age: 36 (18.1%) were born at <30 weeks, 79 (39.9%) between 30 and 33 weeks, 55 (27.7%) between 34 and 36 weeks, and 28 (14.4%) at ≥37 weeks. The demographic and clinical characteristics of the studied population are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">It can be observed that only the extremely preterm children, with less than 30 weeks gestation, had jejunal involvement, at a median of 5% of intestinal involvement, with a statistically significant difference observed when compared with the other gestational age groups (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.010), as shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">In preterm infants, it was observed that the ileum was the intestinal segment most affected by the disease (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.002), as shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. The extent of the ileum affected by the disease was 45% in neonates born at <30 weeks, 40% in those born between 30 and 33 weeks and 6 days, and 20% disease extension in those born at 34–36 weeks and 6 days. It was observed that the closer to the term, the greater the involvement of the diseased colon (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001), as seen in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. An 84% extension of the affected colon was observed in children born at ≥37 weeks, and 32% of the affected colon in preterm infants born at 34–36 weeks and 6 days, with no disease in this segment in the other gestational age ranges. A weak correlation was observed between jejunal disease and gestational age at birth, a correlation that became moderate in the ileum and quite significant when the presence of the disease in the colon was evaluated, with the highest strength of association (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><p id="par0070" class="elsevierStylePara elsevierViewall">Of the total cohort, 90 (45.52%) patients died during the study. No statistical difference was observed in relation to the deaths between the different gestational ages (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.287). NEC was fatal in 18 (50%) neonates at <30 weeks, in 33 (41.8%) born between 30 and 33 weeks, in 22 (40%) born between 34 and 36 weeks, and in 17 (60.7%) born at ≥37 weeks.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">NEC remains the most frequent surgical emergency in the NICU, due to the increased survival of extremely preterm infants, intensive care improvement, and the use of total parenteral nutrition and pulmonary surfactant.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The most affected patients in this study were preterm infants, which in the literature represent 90% of the patients submitted to surgery due to NEC.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1,15</span></a> Differences between the groups studied in the <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> comparison of some clinical and epidemiological characteristics of newborns submitted to surgery due to NEC were observed, but they were due to the difference in the patients’ gestational age, and not due to NEC.</p><p id="par0085" class="elsevierStylePara elsevierViewall">This study showed that of the newborns submitted to surgery due to NEC, the extremely preterm infants had significant jejunal involvement, whereas the preterm infants showed ileal involvement, and in the full-term or near full-term infants, the disease was more common in the colon. This difference observed in the site of NEC may be due to the different disease mechanisms, especially regarding the importance of risk factors in full-term or near full-term infants.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The exact pathophysiology of NEC is not fully understood, and it has not been defined whether a single initial event is responsible for the activation of the cascade of events that culminates with the intestinal lesion, or whether the interaction of several factors is responsible for disease evolution. Disagreements still exist regarding whether the hypoxic/ischemic event is primary or secondary, or if both are initial factors or are the results of insults.</p><p id="par0095" class="elsevierStylePara elsevierViewall">After birth, the intestinal tract is exposed to many types of bacteria, and the diet, be it formula or breast milk. In preterm infants, the intestine must maintain its growth and development until it reaches the length and maturity found in full-term infants. They have increased metabolic demands, which make the intestine even more vulnerable to direct insults to the intestinal wall, as well as bacterial invasion and difficulties in intestinal wall repair and regeneration. This fragility of the intestinal wall and its increased permeability,<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">17,18</span></a> associated with reduced motility and consequent stasis and the repair difficulties after insults to the intestinal wall, make the preterm infant more susceptible to NEC; however, no study has clearly defined whether there are differences regarding the site most often affected by the disease, either the ileum or the colon.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">19,20</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The most common site of NEC occurrence is the terminal ileum and the proximal colon, sites with lower vascularity, suggesting a mismatch in the circulatory system that could be responsible for the disease. Studies on NEC pathogenesis show the importance of ischemia, with the hypoxic/ischemic insult acting directly on the intestinal mucosal damage, breaking the intestinal barrier and promoting bacterial invasion, culminating with the inflammatory cascade activation.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Ischemic insults are more relevant for NEC onset in full-term newborns, with ischemia being the initial event for the triggering of the inflammatory cascade. In preterm infants, in contrast, the probable disease mechanism would be intestinal immaturity, which causes susceptibility to NEC due to reduced intestinal wall protection and repair.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">17,18</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Although this study's postoperative mortality agrees with the literature,<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">2,5</span></a> no difference in mortality according to gestational age at birth was observed. The high mortality in neonates born at ≥37 weeks, although not statistically different from the other groups, may have been due to other severe associated comorbidities, or due to delayed NEC diagnosis and treatment onset.</p><p id="par0115" class="elsevierStylePara elsevierViewall">This study has limitations, as it was performed in a single center and featured a historical cohort. Other studies with larger samples, or even multicenter ones, could corroborate these findings that in neonates submitted to surgery due to NEC, gestational age influences the specific intestinal segment affected by the disease. This could further contribute to better clarify the disease's pathophysiology and the importance of the causal factors in its genesis.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The present study showed that the disease location in newborns submitted to surgery due to NEC was different according to the gestational age. Jejunal involvement was more common in extremely preterm infants, whereas the ileal involvement was more significant in preterm infants, and the colon in full-term or near full-term infants. The mortality of these newborns submitted to surgery due to NEC was not different according to the gestational age at birth.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1027107" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec984713" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1027106" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec984712" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials 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" => "2017-02-13" "fechaAceptado" => "2017-05-08" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec984713" "palabras" => array:5 [ 0 => "Necrotizing enterocolitis" 1 => "Gestational age" 2 => "Enterocolitis location" 3 => "Newborn" 4 => "Premature" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec984712" "palabras" => array:5 [ 0 => "Enterocolite necrosante" 1 => "Idade gestacional" 2 => "Localização da enterocolite" 3 => "Recém-nascido" 4 => "Prematuro" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To evaluate if there are differences regarding disease location and mortality of necrotizing enterocolitis, according to the gestational age at birth, in newborns submitted to surgery due to enterocolite.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A historical cohort study of 198 newborns submitted to surgery due to necrotizing enterecolitis in a tertiary hospital, from November 1991 to December 2012. The newborns were divided into different categories according to gestational age (<30 weeks, 30–33 weeks and 6 days, 34–36 weeks and 6 days, and ≥37 weeks), and were followed for 60 days after surgery. The inclusion criterion was the presence of histological findings of necrotizing enterocolitis in the pathology. Patients with single intestinal perforation were excluded.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The jejunum was the most commonly affected site in extremely premature infants (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.01), whereas the ileum was the most commonly affected site in premature infants (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.002), and the colon in infants born at term (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001). With the increasing gestational age, it was observed that intestinal involvement decreased for the ileum and the jejunum (decreasing from 45% to 0% and from 5% to 0%, respectively), with a progressive increase in colon involvement (0% to 84%). Total mortality rate was 45.5%, and no statistical difference was observed in the mortality at different gestational ages (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.287).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In newborns submitted to surgery due to necrotizing enterocolitis, the disease in extremely preterm infants was more common in the jejunum, whereas in preterm infants, the most affected site was the ileum, and in newborns born close to term, it was the colon. No difference in mortality was observed according to the gestational age at birth.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Avaliar se há diferença de localização e de mortalidade da enterocolite necrosante de acordo com a idade gestacional ao nascimento, em neonatos operados por enterocolite.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Coorte histórica de 198 neonatos operados por enterocolite necrosante em hospital terciário, de novembro de 1991 a dezembro de 2012. Os recém-nascidos operados foram divididos em diferentes categorias de acordo com a idade gestacional (<30 semanas, 30 a 33 semanas e 6 dias, 34 a 36 semanas e 6 dias e ≥37 semanas), e foram seguidos por 60 dias depois da cirurgia. O critério de inclusão foi a presença de achados histológicos de enterocolite necrosante no anatomopatológico, e de exclusão foi a presença de perfuração intestinal única.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">O jejuno foi mais acometido pela ECN nos prematuros extremos (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,01); o íleo mais afetado nos recém-nascidos prematuros (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,002), e o cólon nos recém-nascidos a termo ou próximos ao termo (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001). Com o aumento da idade gestacional, observa-se redução do acometimento do jejuno e do íleo (regrediu de 45% para 0% e de 5% para 0%, respectivamente), e aumento progressivo do acometimento do cólon (0% para 84%). A mortalidade total das crianças operadas por ECN foi de 45,5%; não existiu diferença estatística na mortalidade nas diferentes idades gestacionais (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,287).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusões</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Em recém-nascidos operados por enterocolite necrosante, a doença no jejuno foi mais comum no prematuro extremo, no íleo no prematuro, e a doença no cólon nos recém-nascidos próximos ao termo. Não foi observada diferença de mortalidade de acordo com a idade gestacional ao nascimento.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as: Feldens L, Souza JC, Fraga JC. There is an association between disease location and gestational age at birth in newborns submitted to surgery due to necrotizing enterocolitis. J Pediatr (Rio J). 2018;94:320–4.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1088 "Ancho" => 1653 "Tamanyo" => 82468 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Association between the site of involvement of necrotizing enterocolitis and gestational age, by group.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Data are shown as mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>standard deviation, median (IQR: P25–P75) or percentage (%).</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">M, male; F, female; W, white; nW, non-white; BW, birth weight in grams; SGA, small for gestational age; min., minute; UA, umbilical artery; HMD, hyaline membrane disease.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Variable \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Total \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Gestational age (weeks)</th><th class="td" title="table-head " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">p</span>-value \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>198 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col"><30 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">30–33 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">34–36 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">≥37 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>36 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>79 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>55 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>28 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gender (M/F) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">109/89 (55.1/44.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17/19 (47.2/52.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50/29 (63.3/36.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26/29 (47.3/52.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16/12 (55.1/42.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.217<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ethnicity (W/nW) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">159/39 (80.3/19.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31/5 (86.1/13.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60/19 (75.9/24.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">45/10 (81.8/18.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23/5 (82.1/17.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.616<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vaginal delivery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">109 (55.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 (57.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43 (59.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31 (57.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 (53.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.9481<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BW (g) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1535<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>697 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">905<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>184<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="table-entry " align="left" valign="top">1309<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>445<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1653<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>405<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2754<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>697 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SGA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">72 (36.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 (27.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 (38.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 (45.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 (25.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.193<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Neonatal asphyxia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">58 (29.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (25.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29 (37.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17 (31.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (10.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.059<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Apgar at the 5th min. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.0 (1–10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.4 (4–10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.8 (2–10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.4 (1–10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.6 (4–10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">UA catheterization \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">77 (38.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32 (88.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">40 (50.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (7.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (3.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Heart disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 (12.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 (33.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 (7.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (1.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 (17.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Associated disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">73 (36.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 (57.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">40 (58.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 (26.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (32.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.002<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HMD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">80 (40.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32 (88.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">41 (51.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 (12.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Short intestine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17 (8.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (5.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 (6.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (14.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (7.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.332<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Death \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">90 (45.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 (50.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33 (418) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22 (40.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17 (60.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.258<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1747505.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">chi-squared test.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Analysis of variance.</p>" ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Fisher's exact test.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Demographic and clinical characteristics of patients submitted to surgery due to necrotizing enterocolitis, according to gestational age.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0105" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Necrotizing enterocolitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.C. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 4 | 6 |
| 2024 October | 29 | 19 | 48 |
| 2024 September | 28 | 25 | 53 |
| 2024 August | 41 | 24 | 65 |
| 2024 July | 37 | 24 | 61 |
| 2024 June | 16 | 18 | 34 |
| 2024 May | 21 | 11 | 32 |
| 2024 April | 22 | 17 | 39 |
| 2024 March | 17 | 17 | 34 |
| 2024 February | 22 | 25 | 47 |
| 2024 January | 22 | 24 | 46 |
| 2023 December | 16 | 26 | 42 |
| 2023 November | 26 | 33 | 59 |
| 2023 October | 18 | 34 | 52 |
| 2023 September | 17 | 37 | 54 |
| 2023 August | 20 | 12 | 32 |
| 2023 July | 17 | 10 | 27 |
| 2023 June | 10 | 7 | 17 |
| 2023 May | 23 | 13 | 36 |
| 2023 April | 24 | 12 | 36 |
| 2023 March | 42 | 16 | 58 |
| 2023 February | 48 | 15 | 63 |
| 2023 January | 19 | 17 | 36 |
| 2022 December | 44 | 28 | 72 |
| 2022 November | 24 | 26 | 50 |
| 2022 October | 42 | 39 | 81 |
| 2022 September | 24 | 26 | 50 |
| 2022 August | 28 | 33 | 61 |
| 2022 July | 20 | 35 | 55 |
| 2022 June | 27 | 35 | 62 |
| 2022 May | 27 | 37 | 64 |
| 2022 April | 22 | 26 | 48 |
| 2022 March | 33 | 35 | 68 |
| 2022 February | 18 | 25 | 43 |
| 2022 January | 24 | 14 | 38 |
| 2021 December | 14 | 24 | 38 |
| 2021 November | 11 | 16 | 27 |
| 2021 October | 16 | 18 | 34 |
| 2021 September | 7 | 11 | 18 |
| 2021 August | 15 | 10 | 25 |
| 2021 July | 6 | 4 | 10 |
| 2021 June | 14 | 12 | 26 |
| 2021 May | 13 | 12 | 25 |
| 2021 April | 18 | 6 | 24 |
| 2021 March | 15 | 11 | 26 |
| 2021 February | 8 | 5 | 13 |
| 2021 January | 10 | 10 | 20 |
| 2020 December | 18 | 14 | 32 |
| 2020 November | 19 | 15 | 34 |
| 2020 October | 10 | 14 | 24 |
| 2020 September | 21 | 11 | 32 |
| 2020 August | 5 | 16 | 21 |
| 2020 July | 9 | 20 | 29 |
| 2020 June | 12 | 4 | 16 |
| 2020 May | 15 | 19 | 34 |
| 2020 April | 14 | 10 | 24 |
| 2020 March | 16 | 13 | 29 |
| 2020 February | 20 | 14 | 34 |
| 2020 January | 14 | 15 | 29 |
| 2019 December | 21 | 16 | 37 |
| 2019 November | 14 | 7 | 21 |
| 2019 October | 27 | 10 | 37 |
| 2019 September | 8 | 10 | 18 |
| 2019 August | 10 | 6 | 16 |
| 2019 July | 26 | 18 | 44 |
| 2019 June | 18 | 20 | 38 |
| 2019 May | 27 | 10 | 37 |
| 2019 April | 22 | 7 | 29 |
| 2019 March | 19 | 14 | 33 |
| 2019 February | 16 | 7 | 23 |
| 2019 January | 11 | 10 | 21 |
| 2018 December | 21 | 9 | 30 |
| 2018 November | 62 | 12 | 74 |
| 2018 October | 134 | 16 | 150 |
| 2018 September | 44 | 6 | 50 |
| 2018 August | 15 | 3 | 18 |
| 2018 July | 29 | 6 | 35 |
| 2018 June | 34 | 8 | 42 |
| 2018 May | 22 | 12 | 34 |
| 2018 April | 1 | 3 | 4 |
| 2018 March | 5 | 8 | 13 |
| 2018 February | 0 | 4 | 4 |
| 2018 January | 1 | 3 | 4 |
| 2017 December | 1 | 2 | 3 |
| 2017 November | 0 | 2 | 2 |
| 2017 October | 2 | 10 | 12 |
| 2017 September | 0 | 5 | 5 |
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