Toxic epidermal necrolysis; 15 years'' experience in a Dutch burns centre

BACKGROUND: Toxic epidermal necrolysis (TEN) is a severe and potentially fatal drug reaction characterized by an extensive skin rash with blisters and exfoliation, frequently accompanied by mucositis. The wounds caused by TEN are similar to second-degree burns and severe cases may involve large areas of skin loss. OBJECTIVES: Analysis of our results in patients with TEN and evaluation of the variety of therapeutic interventions that has been studied and suggested in TEN. PATIENTS/METHODS: Retrospective analysis of 19 consecutive patients with TEN treated in our burns centre between 1989 and 2004. RESULTS: Immediate withdrawal of any potentially fatal drug, maximum supportive care, and a restricted and tailored antibiotic, medical and surgical treatment regimen confined mortality to 21%, whereas prognosis scores like APACHE II and SCORTEN predicted mortality of 22 and 30%, respectively. A positive contribution of selective digestive decontamination is suggested but has yet to be established. CONCLUSIONS: Because of a potentially fatal outcome, fast referral of a patient suspected of TEN to a specialized centre (mostly a burns unit or specialized dermatology centre) for expert wound management and tailored comprehensive care is strongly advised and contributes to survival.     

The introduction of low-osmolar contrast agents in radiology. Medical, economic, legal, and public policy issues

This case study of the public policy implications of introducing a new technology in radiology, namely, low-osmolar contrast media (LOCM), raises the issues of whether and how to place appropriate limits on new technologies. Although these contrast media represent small episodic costs, they may add up to an aggregate expenditure of nearly $1 billion per year if used for all contrast injections. As a result, this technology raises a number of important medical, economic, legal, and public policy questions. Our cost-effectiveness analysis and an analysis of the medical evidence suggest that LOCM should be limited to high-risk patients. We discuss in this article how the legal system might respond to such limitations, and we consider various public policy options for adopting restrictions on use. We conclude that the medical profession should take the lead in developing protocols for appropriate assessment, reimbursement, and use of LOCM.     

Characteristics of the 19S and 7S response to bacteriophage ΦX174 in the fowl

After intravenous injection of 10¹⁰ plaque forming particles of ØX174 bacteriophage into White Rock fowls, immune elimination began at 30 hours and viable phage was cleared from the circulation by 50–52 hours, the approximate time at which detectable antibody appeared. Little change was noted in the serum neutralizing activity in the interval from 44 to 217 days after injection, at which time the birds were reinjected with ØX174.

Sephadex Peak I (19S globulin) accounted for most of the early activity of the primary response. By Day 9 most of the activity had shifted to Peak II (7S globulin). In the secondary response, the shift had occurred by Day 4. Both 19S and 7S globulin fractions showed an increase in activity when compared to the same days of the primary response, but the 7S increase was proportionately greater.

All sera and serum fractions (whether 19S or 7S) were sensitive to reduction with 2-mercaptoethanol, but became, less sensitive during the course of immunization.

With regard to the production of 19S antibody, White Rock fowls showed a different response to the particulate antigen ØX174 compared with the response to injection of the soluble antigen, bovine serum albumin. There is evidence of immunological memory in the 19S response to ØX174.