Severe persistent hypocholesterolemia after emergency gastrointestinal surgery predicts in-hospital mortality in critically ill patients with diffuse peritonitis

<div><p>Background</p><p>Plasma cholesterol acts as a negative acute phase reactant. Total cholesterol decreases after surgery and in various pathological conditions, including trauma, sepsis, burns, and liver dysfunction. This study aimed to determine whether hypocholesterolemia after emergency gastrointestinal (GI) surgery is associated with in-hospital mortality in patients with diffuse peritonitis.</p><p>Methods</p><p>The medical records of 926 critically ill patients who had undergone emergency GI surgery for diffuse peritonitis, between January 2007 and December 2015, were retrospectively analyzed. The integrated areas under the curve (iAUCs) were calculated to compare the predictive accuracy of total cholesterol values from postoperative days (PODs) 0, 1, 3, and 7. Cox proportional hazard regression modeling was performed for all possible predictors identified in the univariate and multivariable analyses.</p><p>Results</p><p>The total cholesterol level measured on POD 7 had the highest iAUC (0.7292; 95% confidence interval, 0.6696–0.7891) and was significantly better at predicting in-hospital mortality than measurements on other days. The optimal total cholesterol cut-off value for predicting in-hospital mortality was 61 mg/dL and was determined on POD 7. A Cox proportional hazard regression analysis revealed that a POD 7 total cholesterol level < 61 mg/dL was an independent predictor of in-hospital mortality after emergency GI surgery (hazard ratio, 3.961; 95% confidence interval, 1.786–8.784).</p><p>Conclusion</p><p>Severe persistent hypocholesterolemia (<61 mg/dL) on POD 7 independently predicted in-hospital mortality, after emergency GI surgery, in critically ill patients with diffuse peritonitis.</p></div

Kaplan–Meier curve based on hypocholesterolemia severity (total cholesterol level ≥61 mg/dL versus total cholesterol level <61 mg/dL; log-rank test, <i>P</i> < 0.0001).

<p>Kaplan–Meier curve based on hypocholesterolemia severity (total cholesterol level ≥61 mg/dL versus total cholesterol level <61 mg/dL; log-rank test, <i>P</i> < 0.0001).</p

Univariate and multivariable Cox proportional hazards model for in-hospital mortality.

<p>Univariate and multivariable Cox proportional hazards model for in-hospital mortality.</p

Flow diagram of the patient selection process.

<p>Flow diagram of the patient selection process.</p

Comparison of the changes in total cholesterol levels between survivors and nonsurvivors.

<p>The time variations in total cholesterol levels were significantly different between survivors and nonsurvivors (Greenhouse-Geisser corrected, <i>P</i> < 0.001, using repeated-measures analysis of variance).</p

Time-dependent receiver operating curve analysis to evaluate the predictive accuracy of each measurement day.

<p>Results in the top right-hand corner of the figure indicate the integrated area under the curve (iAUC) and 95% confidence interval. The iAUC is a measure of the predictive accuracy for in-hospital mortality on each measurement day. The cholesterol level measured on postoperative day 7 had the highest iAUC.</p

Baseline characteristics of the total population.^a

<p>Baseline characteristics of the total population.<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0200187#t001fn002" target="_blank">^a</a></p

Estimated iAUC differences using a bootstrapping method.

<p>Estimated iAUC differences using a bootstrapping method.</p

Note sous Cour d'appel de Paris, première Chambre A, 31 août 2006, Barrault contre Gaz de France et Cirelli

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Circadian Patterns of Intraocular Pressure Fluctuation among Normal-Tension Glaucoma Optic Disc Phenotypes - Fig 4

<p>Average 24-h rhythms of habitual-position IOP in all patients (A) and in three subgroups of patients (B, C, and D) based on the cosinor model in the myopic glaucomatous group.</p