Outcome of patients with toxic epidermal necrolysis syndrome revisited

Toxic epidermal necrolysis syndrome is an uncommon, acute, life-threatening, medication-induced disorder with a reported mortality rate of 20 to 60 percent. Different variables have been identified as risk factors. The extent to which these variables, when combined, affect the mortality and outcome in toxic epidermal necrolysis syndrome patients has not yet been reliably defined. Because of the high mortality rate, the logistic analysis of studied variables was performed to see whether a prognostic algorithm could be developed to aid the management of these patients. Thus, a retrospective review of 56 consecutive toxic epidermal necrolysis syndrome patients treated over a period of 13 years was undertaken in the authors' burn center. The demographics included age, sex, race, and total body surface area involved. The other variables studied were comorbidities, sepsis, steroid administration, and the interval between onset of rash and burn center admission. Data were subjected to Fisher's exact test and logistic analysis. Thirty-six patients (64.3 percent) were alive and 20 (35.7 percent) died. Univariate analysis indicated that the male/female ratio was 12:24 for survivors and 9:11 for nonsurvivors (p = 0.4). The white/nonwhite ratio was 80 percent for survivors and 54 percent for nonsurvivors (p = 0.58). The median age was 48.4 +/- 22.8 years (survivors, 41.7 +/- 22.0; nonsurvivors, 60.5 +/- 19.5; p = 0.002). Total body surface area involvement for survivors was 56.9 +/- 32 and 77.7 +/- 21 for nonsurvivors (p = 0.005). The presence of one or more comorbidities between the two groups differed (53 percent survivors and 90 percent nonsurvivors, p = 0.007), indicating eight times higher odds of dying in their presence. The average time between the onset of symptoms and admission to the burn unit was 5.25 +/- 3.4 days for survivors and 7.15 +/- 4.5 days for nonsurvivors (p = 0.08). The presence of sepsis (19.4 percent survivors, 95 percent nonsurvivors, p < 0.001) decreased odds for survival by a factor of 79. Steroids given as a single dose or multiple doses before the patient's transfer to the burn unit were not significantly associated with death (44 percent survivors, 65 percent nonsurvivors, p = 0.14). A multivariate logistic regression model yielded odds ratios of 1.11 (95 percent confidence interval, 1.03 to 1.19) for age in years, 304 (95 percent confidence interval, 8.83 to 10,400) for the presence of sepsis, and 1.03 (95 percent confidence interval, 0.99 to 1.08) for body surface area in percent. All those entering the burn unit with sepsis died. Equivalently, no survivors had sepsis before admission to the burn unit, whereas 55 percent of nonsurvivors had sepsis before admission and 40 percent developed sepsis after admission. When investigating the effect of age and sepsis, no patients over age 60 ever having sepsis survived, whereas all those who were under 60 and without sepsis survived. Likewise, all patients whose age was over 60 and whose total body surface area involved was over 60 percent died. The main factors contributing to the mortality from toxic epidermal necrolysis syndrome, when considering covariates separately, are the presence of sepsis at any time (odds ratio, 79), the presence of comorbidities (odds ratio, 8.05), age, and total body surface area, whereas multivariate models suggested age (odds ratio per year of additional age, 1.11), total body surface area (odds ratio per additional percent of body surface area, 1.03), and the presence of sepsis (odds ratio, 304). By using the actual coefficients in the logistic model, the log odds that the patient will die as the result of his or her condition can be summarized in the following formula: -11.5 + (10 percent of the patient's age + 3 percent of total body surface area + 5.75 if sepsis is present). The awareness of the importance of these covariates, and their early recognition as risk factors, should offer a focused approach to the patients' management and improve their outcome.     

Asymptomatic hyperuricemia: impact of ultrasonography

Thirty-five patients (23 males) with asymptomatic hyperuricemia for at least two years underwent two-dimensional ultrasonography of knees and ankles. Urate deposits (tophi) in tendons, synovium, and other soft tissues were detected in 12 patients (34%). Increased vascularity (inflammation) was evident in 8 of these patients (23%). Tophi were more frequently found in knees than in ankles and were especially prevalent in the distal patellar tendon. The presence of tophi was unrelated to the known duration of hyperuricemia (mean, 5 years). Ultrasonography allows detection of tophi and inflammation in a third and in a fourth, respectively, of asymptomatic hyperuricemic patients.     

别嘌醇对高尿酸血症大鼠血清脂联素的影响

目的观察高尿酸血症大鼠血清脂联素的改变,探讨别嘌醇对高尿酸血症大鼠血清脂联素的影响及意义。方法 36只雄性SD大鼠随机分为3组。使用高酵母膏饲料联合氧嗪酸钾混悬液腹腔注射6周诱导大鼠高尿酸血症模型。别嘌醇治疗组除给予造模剂外同时给予别嘌醇灌胃。6周后处死大鼠,检测血清尿酸、脂联素、一氧化氮,免疫组化法检测大鼠主动脉内膜层eNOS的表达量。结果与正常对照组相比模型组大鼠血尿酸显著升高[(216.0±6.2)vs(45.1±5.6),P<0.05],血清脂联素、一氧化氮及主动内膜层内皮型一氧化氮合酶表达量显著降低[(52.6±7.9)vs(63.6±9.2),(17.2±3.3)vs(24.1±2.0),(38.3±4.5)vs(48.3±4.2),P<0.05]。别嘌醇治疗组血尿酸降低[(44.8±4.3)vs(216.0±6.2),P<0.05],血清脂联素和一氧化氮水平升高[(159.6±9.2)vs(52.6±7.9),(22.1±2.2)vs(17.2±3.3),P<0.05],主动脉内膜内皮型一氧化氮合酶蛋白表达增加[(46.1±4.2)vs(38.3±4.5),P<0.05]。脂联素与一氧化氮呈正相关(r=0.057),与血尿酸呈负相关(r=-0.48)。结论别嘌醇处理可一定程度逆转高尿酸血症可诱导的大鼠血清脂联素的降低,别嘌醇可能是上调内皮型一氧化氮合酶的激动剂。     

Treating hyperuricemia of gout: safety and efficacy of febuxostat and allopurinol in older versus younger subjects

Despite an increasing incidence of gout in older age patients with multiple metabolic and cardiovascular comorbidities, there are limited data addressing whether currently available urate-lowering therapy is comparably effective and safe in older (≥65 years of age) versus younger (<65 years of age) patients. In this secondary analysis of data from the CONFIRMS trial, we found that among 374 older subjects, urate-lowering therapy with approved doses of febuxostat or commonly prescribed doses of allopurinol was at least comparable to that in 1894 younger subjects and was well tolerated despite high rates of renal impairment and cardiovascular comorbidities in the older subjects.