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Use of SCORTEN to Accurately Predict Mortality in Patients With Toxic Epidermal Necrolysis in the United States

Use of SCORTEN to Accurately Predict Mortality in Patients With Toxic Epidermal Necrolysis in the... The SCORTEN is an illness severity score specific to toxic epidermal necrolysis (TEN) developed and validated in Europe by Bastuji-Garin et al.1 Recently, 2 reports of the use of the SCORTEN toassess the changes in mortality in patients treated with intravenous immune globulin have shown contradictory results, bringing into question the applicabilityof the SCORTEN outside Europe.2,3 We therefore retrospectively analyzed our patients with TEN before using intravenousimmune globulin to determine whether the SCORTEN would accurately predict mortality. Methods After receiving institutional review board approval, we reviewed hospital administrative and patient records for patients with TEN admitted to the Departmentof Dermatology at the University of Miami/Cedars Medical Center, Miami, Fla, from 1993 through 1998. Diagnosis was based on clinical and histologic findings,and patients were treated in a systematic fashion according to a standardized protocol.2 The SCORTEN is based on 7 risk factors, recorded within the first 24 hours of admission: age greater than 40 years, presence of malignancy, involvementof more than 10% of body surface area, pulse greater than 120/min, glucose level greater than 252 mg/dL (14.0 mmol/L), carbon dioxide level less than20 mEq/L, and serum urea nitrogen level greater than 27 mg/dL (9.6 mmol/L). Patients with 0 or 1 risk factor on the SCORTEN have an expected mortalityrate of 3.2%; 2 risk factors, 12.1%; 3 risk factors, 35.3%; 4 risk factors, 58.3%; and 5 or more risk factors, 90%.1 The 7 SCORTEN risk factors and final score for our patients were recorded. Standardized mortality ratio analysis ([Σobserved deaths/Σexpecteddeaths] × 100) was then used.2 Results Twenty-four patients with TEN were included in this study (Table 1). Phenytoin was implicated in 7 cases and sulfonamides in 5. Patients were admitted on average 4.2 days afterTEN began and remained hospitalized for an average of 22.3 days. Eight patients died; the mean length of stay for survivors was 13.3 days. Table 1. View LargeDownload Clinical and SCORTEN Data According to the SCORTEN, the expected mortality was 8.771 patients (36.5%) (Table 2). The actualmortality was 8 (33.3%). With the use of standardized mortality ratio analysis, our actual mortality in patients with TEN was not statistically significantcompared with predicted risk (standardized mortality ratio, 0.912; 95% confidence interval, 0.393-1.800). Table 2. View LargeDownload Comparison of SCORTEN Predicted Mortality and Actual Mortality Comment The SCORTEN was developed in France by Bastuji-Garin et al1 from 23 suspected important variables evaluated from 165 patients with TEN. Sevenvariables were found to accurately predict mortality, and this finding was validated in 75 additional patients from Europe. Our study supports the SCORTEN'sability to predict mortality in patients with TEN in the United States receiving supportive intensive care. The SCORTEN can also serve to help determine efficacy of therapeutic interventions such as intravenous immune globulin.4,5 Twostudies using the SCORTEN to compare the effect of intravenous immune globulinon expected mortality found contradictory results.2,3 Trentet al2 found an 83% reduction in predicted mortality, while Bachot et al3 reportedan increase in mortality. Differences may be due to dose of intravenous immuneglobulin used (2 g/kg vs 4 g/kg), or time from onset to the use of intravenousimmune globulin (4.1 vs 3.4 days). It has been argued that the SCORTEN, developed in France, may not be applicable to populations in other countries.1 On the basis of the SCORTEN, our expected mortality was 8.771 patients(36.5%), not different from the actual mortality, 8 patients (33.3%). Theactual and expected mortalities were compared by means of standardized mortalityratio analysis, and significant differences were not found. Although our studysample was small, the SCORTEN appears to predict mortality outside of Europe and suggests that differences in response to intravenous immune globulin (mortality,6.25% vs 33.3%) are due to other factors, rather than the SCORTEN's ability to predict mortality. The authors have no relevant financial interest in this article. Correspondence: Dr Kerdel, Department of Dermatology, University of Miami, PO Box 016250, Miami, FL 33136. References 1. Bastuji-Garin SFouchard NBertocchi MRoujeau JCRevuz JWolkenstein P SCORTEN: a severity-of-illness score for toxic epidermal necrolysis J Invest Dermatol. 2000;115149- 153PubMedGoogle ScholarCrossref 2. Trent JTKirsner RSRomanelli PKerdel FA Analysis of intravenous immunoglobulin for the treatment of toxic epidermal necrolysis using SCORTEN: the University of Miami experience Arch Dermatol. 2003;13939- 43PubMedGoogle Scholar 3. Bachot NRevuz JRoujeau JC Intravenous immunoglobulin treatment for Stevens-Johnson syndrome andtoxic epidermal necrolysis: a prospective noncomparative study showing nobenefit on mortality or progression Arch Dermatol. 2003;13933- 36PubMedGoogle ScholarCrossref 4. Viard IWehrli PBullani R et al. Inhibition of toxic epidermal necrolysis by blockade of CD95 with human intravenous immunoglobulin Science. 1998;282490- 493PubMedGoogle ScholarCrossref 5. Prins CKerdel FAPadilla S et al. for the TEN-IVIG Study Group, Treatment of toxic epidermal necrolysis with high-dose intravenous immunoglobulins: multicenter retrospective analysis of 48 consecutive cases Arch Dermatol. 2003;13926- 32PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Dermatology American Medical Association

Use of SCORTEN to Accurately Predict Mortality in Patients With Toxic Epidermal Necrolysis in the United States

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Publisher
American Medical Association
Copyright
Copyright © 2004 American Medical Association. All Rights Reserved.
ISSN
0003-987X
eISSN
1538-3652
DOI
10.1001/archderm.140.7.890
Publisher site
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Abstract

The SCORTEN is an illness severity score specific to toxic epidermal necrolysis (TEN) developed and validated in Europe by Bastuji-Garin et al.1 Recently, 2 reports of the use of the SCORTEN toassess the changes in mortality in patients treated with intravenous immune globulin have shown contradictory results, bringing into question the applicabilityof the SCORTEN outside Europe.2,3 We therefore retrospectively analyzed our patients with TEN before using intravenousimmune globulin to determine whether the SCORTEN would accurately predict mortality. Methods After receiving institutional review board approval, we reviewed hospital administrative and patient records for patients with TEN admitted to the Departmentof Dermatology at the University of Miami/Cedars Medical Center, Miami, Fla, from 1993 through 1998. Diagnosis was based on clinical and histologic findings,and patients were treated in a systematic fashion according to a standardized protocol.2 The SCORTEN is based on 7 risk factors, recorded within the first 24 hours of admission: age greater than 40 years, presence of malignancy, involvementof more than 10% of body surface area, pulse greater than 120/min, glucose level greater than 252 mg/dL (14.0 mmol/L), carbon dioxide level less than20 mEq/L, and serum urea nitrogen level greater than 27 mg/dL (9.6 mmol/L). Patients with 0 or 1 risk factor on the SCORTEN have an expected mortalityrate of 3.2%; 2 risk factors, 12.1%; 3 risk factors, 35.3%; 4 risk factors, 58.3%; and 5 or more risk factors, 90%.1 The 7 SCORTEN risk factors and final score for our patients were recorded. Standardized mortality ratio analysis ([Σobserved deaths/Σexpecteddeaths] × 100) was then used.2 Results Twenty-four patients with TEN were included in this study (Table 1). Phenytoin was implicated in 7 cases and sulfonamides in 5. Patients were admitted on average 4.2 days afterTEN began and remained hospitalized for an average of 22.3 days. Eight patients died; the mean length of stay for survivors was 13.3 days. Table 1. View LargeDownload Clinical and SCORTEN Data According to the SCORTEN, the expected mortality was 8.771 patients (36.5%) (Table 2). The actualmortality was 8 (33.3%). With the use of standardized mortality ratio analysis, our actual mortality in patients with TEN was not statistically significantcompared with predicted risk (standardized mortality ratio, 0.912; 95% confidence interval, 0.393-1.800). Table 2. View LargeDownload Comparison of SCORTEN Predicted Mortality and Actual Mortality Comment The SCORTEN was developed in France by Bastuji-Garin et al1 from 23 suspected important variables evaluated from 165 patients with TEN. Sevenvariables were found to accurately predict mortality, and this finding was validated in 75 additional patients from Europe. Our study supports the SCORTEN'sability to predict mortality in patients with TEN in the United States receiving supportive intensive care. The SCORTEN can also serve to help determine efficacy of therapeutic interventions such as intravenous immune globulin.4,5 Twostudies using the SCORTEN to compare the effect of intravenous immune globulinon expected mortality found contradictory results.2,3 Trentet al2 found an 83% reduction in predicted mortality, while Bachot et al3 reportedan increase in mortality. Differences may be due to dose of intravenous immuneglobulin used (2 g/kg vs 4 g/kg), or time from onset to the use of intravenousimmune globulin (4.1 vs 3.4 days). It has been argued that the SCORTEN, developed in France, may not be applicable to populations in other countries.1 On the basis of the SCORTEN, our expected mortality was 8.771 patients(36.5%), not different from the actual mortality, 8 patients (33.3%). Theactual and expected mortalities were compared by means of standardized mortalityratio analysis, and significant differences were not found. Although our studysample was small, the SCORTEN appears to predict mortality outside of Europe and suggests that differences in response to intravenous immune globulin (mortality,6.25% vs 33.3%) are due to other factors, rather than the SCORTEN's ability to predict mortality. The authors have no relevant financial interest in this article. Correspondence: Dr Kerdel, Department of Dermatology, University of Miami, PO Box 016250, Miami, FL 33136. References 1. Bastuji-Garin SFouchard NBertocchi MRoujeau JCRevuz JWolkenstein P SCORTEN: a severity-of-illness score for toxic epidermal necrolysis J Invest Dermatol. 2000;115149- 153PubMedGoogle ScholarCrossref 2. Trent JTKirsner RSRomanelli PKerdel FA Analysis of intravenous immunoglobulin for the treatment of toxic epidermal necrolysis using SCORTEN: the University of Miami experience Arch Dermatol. 2003;13939- 43PubMedGoogle Scholar 3. Bachot NRevuz JRoujeau JC Intravenous immunoglobulin treatment for Stevens-Johnson syndrome andtoxic epidermal necrolysis: a prospective noncomparative study showing nobenefit on mortality or progression Arch Dermatol. 2003;13933- 36PubMedGoogle ScholarCrossref 4. Viard IWehrli PBullani R et al. Inhibition of toxic epidermal necrolysis by blockade of CD95 with human intravenous immunoglobulin Science. 1998;282490- 493PubMedGoogle ScholarCrossref 5. Prins CKerdel FAPadilla S et al. for the TEN-IVIG Study Group, Treatment of toxic epidermal necrolysis with high-dose intravenous immunoglobulins: multicenter retrospective analysis of 48 consecutive cases Arch Dermatol. 2003;13926- 32PubMedGoogle ScholarCrossref

Journal

Archives of DermatologyAmerican Medical Association

Published: Jul 1, 2004

Keywords: epidermal necrolysis, toxic,scorten

References