Toxic epidermal necrolysis is an adverse immunological skin reaction secondary in most cases to the administration of a drug. Toxic epidermal necrolysis, Stevens-Johnson syndrome, and multiform exudative erythema are part of the same disease spectrum. The mortality rate from toxic epidermal necrolysis is approximately 30%. The pathophysiology of toxic epidermal necrolysis is similar in many respects to that of superficial skin burns. Mucosal involvement of the ocular and genital epithelium is associated with serious sequelae if the condition is not treated early. It is generally accepted that patients with toxic epidermal necrolysis are better treated in burn units, which are experienced in the management of patients with extensive skin loss. Treatment includes support, elimination, and coverage with biosynthetic derivatives of the skin in affected areas, treatment of mucosal involvement, and specific immunosuppressive treatment. Of the treatments tested, only immunoglobulin G and cyclosporin A are currently used in most centers, even though there is no solid evidence to recommend any specific treatment. The particular aspects of the treatment of this disease include the prevention of sequelae related to the formation of synechiae, eye care to prevent serious sequelae that can lead to blindness, and specific immunosuppressive treatment. Better knowledge of the management principles of toxic epidermal necrolysis will lead to better disease management, higher survival rates, and lower prevalence of sequelae.
Background Many specific prognostic risk scores have been validated for myocardial infarction (MI), such as the Global Registry of Acute Coronary Events (GRACE) 2.0. Other general risk scores are used in intensive care units (ICUs), such as the Acute Physiologic and Chronic Health Evaluation (APACHE) II and the Simplified Acute Physiology Score (SAPS) II. Purpose Compare the ability of GRACE 2.0, APACHE II and SAPS II risk scores to estimate in-hospital, 3- and 12-month mortality after primary angioplasty (PA) for ST-segment elevation MI (STEMI). Methods Retrospective cohort of 427 consecutive STEMI patients (64 years [55–75]; 78% men) admitted to a general ICU between November-2013 and February-2017. We used Area under the Receiver Operating Characteristic (ROC) curve (AUC) analysis to asses performance of risk scores, and the Hosmer-Lemeshow (HL) goodness of fit test and the Standardized Mortality Ratio (SMR) to assess calibration. Results All risk scores were associated with in-hospital, 3- and 12-month mortality (P<0.001). SAPS II had the highest sensitivity for short-term mortality and the highest AUC for in-hospital, 3- and 12-month mortality (Figure). SAPS II had the highest calibration and the less underestimation of mortality in all follow-up periods analysed (Table). Performance of prognostic risk scores Youden index (J) Sensitivity (%) Specificity (%) AUC (95% CI) H-L (P value) SMR In-Hospital mortality (5.4%) SAPS II 32 87.0 89.4 0.938 (0.887–0.988) 1.826 (0.969) 1.64 GRACE 2.0 150 86.9 83.7 0.922 (0.865–0.979) 8.111 (0.423) 1.77 APACHE II 17 82.6 93.8 0.896 (0.841–0.986) 11.941 (0.154) 1.92 3-month mortality (5.6%) SAPS II 32 79.2 89.1 0.913 (0.854–0.973) 3.635 (0.821) 1.85 GRACE 2.0 150 79.1 85.4 0.902 (0.842–0.962) 5.149 (0.742) 2.0 APACHE II 17 79.1 93.8 0.882 (0.792–0.971) 9.244 (0.322) 2.0 12-month mortality (7.0%) SAPS II 32 73.3 89.7 0.880 (0.809–0.951) 1.994 (0.960) 1.58 GRACE 2.0 150 76.7 84.1 0.878 (0.816–0.941) 4.073 (0.850) 2.31 APACHE II 17 70.0 92.4 0.824 (0.722–0.927) 7.464 (0.487) 2.14 AUC: Area under the curve; H-L: Hosmer-Lemeshow; SMR: Standardized Mortality Ratio. Area under the ROC curves (AUC) Conclusions SAPS II represents the best model to estimate mortality in this cohort of STEMI patients, with an appropriate calibration and less underestimation of mortality. Underestimation of mortality showed by all risk scores suggests the need of creating new risk prediction models that improve identification of high risk STEMI patients.
Background Gender-based differences in mortality of patients with ST-segment elevation myocardial infarction (STEMI) have been reported. However, controversy exists about the impact of female gender on mortality after correcting for baseline risk differences. Purpose Assess gender-based mortality in a cohort of STEMI patients following primary angioplasty. Methods Retrospective cohort of 427 consecutive STEMI patients (64 years [55–75]; 78% men) admitted to a general ICU between November-2013 and February-2017. We used Kaplan-Meier and Cox regression models for survival analysis. The Clinical Frailty Scale (CFS) was used to assess frailty. Results Women were older and had a higher GRACE 2.0 and frailty (CFS≥4). Women had lower creatine-phosphokinase and albumin levels and higher B-natriuretic peptide levels, despite the lack of gender-based differences in left ventricular ejection fraction (LVEF) and MI size and location. One-year mortality rate was higher in women, most often from cardiogenic shock during admission and at 30-day follow-up (Table). After Cox regression analysis, women had a 2.23-fold higher risk of one-year mortality compared with men (Figure), independently of age, frailty, GRACE 2.0, LVEF and inotropic agents requirements. Baseline characteristics Women (n=93) Men (n=334) P value One-year mortality, n (%) 15 (16.1) 15 (4.5) <0.001 Cardiogenic shock, n (%) 10 (62.5) 6 (37.5) <0.001 Age (years) 70.8 [51.2–80.3] 61.9 [54.2–71.8] <0.001 Hypertension, n (%) 54 (58.1) 149 (44.6) 0.022 GRACE 2.0 129 [104.5–156] 112 [94–139] 0.001 Clinical Frailty Scale≥4, n (%) 28 (30.1) 32 (9.6) <0.001 MI location (anterior), n (%) 42 (45.2) 152 (45.5) 0.953 Creatin-phosphokinase (UI/L) 1040 [300.5–2134] 1517 [620.5–2852.8] 0.004 High-sensitivity troponin I (pg/mL) 4003 [62.1–48526.6] 9070 [65.8–65893] 0.473 Left ventricular ejection fraction (%) 52 [40–60] 55 [45–60] 0.465 B-natriuretic peptide (pg/mL) 241.1 [99.9–896.9] 103.6 [28.3–259.2] <0.001 Albumin (g/L) 36.1 [34.3–38.5] 38.4 [35.6–40.5] <0.001 Inotropic agents, n (%) 14 (15.1) 26 (7.8) 0.033 Kaplan-Meier and Cox survival curves. Conclusions Female gender is an independent predictor of one-year mortality in STEMI patients, regardless of age, clinical severity and frailty. A potential myocardial disfunction probably mediated by an increased frailty, may play a role in the high mortality rate among women after STEMI.
Background Malnutrition and sarcopenia are common features of frailty. Prevalence of frailty among ST-segment elevation myocardial infarction (STEMI) patients is higher in women than men. Purpose Assess gender-based differences in the impact of nutritional risk index (NRI) and frailty in one-year mortality rate among STEMI patients following primary angioplasty (PA). Methods Cohort of 321 consecutive patients (64 years [54–75]; 22.4% women) admitted to a general ICU after PA for STEMI. NRI was calculated as 1.519 × serum albumin (g/L) + 41.7 × (actual body weight [kg]/ideal weight [kg]). Vulnerable and moderate to severe NRI patients were those with Clinical Frailty Scale (CFS)≥4 and NRI<97.5, respectively. We used Kaplan-Meier survival model. Results Baseline and mortality variables of 4 groups (NRI-/CFS-; NRI+/CFS-; NRI+/CFS- and NRI+/CFS+) are depicted in the Table. Prevalence of malnutrition, frailty or both were significantly greater in women (34.3%, 10% y 21.4%, respectively) than in men (28.9%, 2.8% y 6.0%, respectively; P<0.001). Women had greater mortality rate (20.8% vs. 5.2%: OR 4.78, 95% CI, 2.15–10.60, P<0.001), mainly from cardiogenic shock (P=0.003). Combination of malnutrition and frailty significantly decreased cumulative one-year survival in women (46.7% vs. 73.3% in men, P<0.001) Conclusion Among STEMI patients undergoing PA, the prevalence of malnutrition and frailty are significantly higher in women than in men. NRI and frailty had an independent and complementary prognostic impact in women with STEMI. Kaplan-Meier and Cox survival curves Funding Acknowledgement Type of funding source: None
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