Department of Internal Medicine, Singapore General Hospital, Singapore.
Health Services & Systems Research, Duke-NUS Medical School, Singapore.
JAMA Dermatol. 2022 Feb 1;158(2):160-166. doi: 10.1001/jamadermatol.2021.5119.
Epidermal necrolysis is a severe cutaneous adverse reaction in which severe systemic inflammation results in extensive epithelial keratinocyte necrosis. The most commonly used prognostic score in epidermal necrolysis, the Severity-of-Illness Score for Toxic Epidermal Necrolysis (SCORTEN), was recently found to overestimate mortality in contemporary cohorts. Identification of independent prognostic markers may help to stratify risk more accurately.
This study evaluates the association between novel inflammatory markers and in-hospital mortality in patients with epidermal necrolysis to study the incremental prognostic value of these markers in combination with SCORTEN.
DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study was conducted over a 17-year period from 2003 to 2019. Patients were enrolled from Singapore General Hospital, the national referral center for epidermal necrolysis. A total of 196 patients with epidermal necrolysis were recruited, 4 (2%) of whom were excluded owing to incomplete data.
The main outcome assessed was the in-hospital mortality rate. Discrimination and calibration of risk scores were assessed using the area under the receiver operating characteristic curve (AUC) and calibration plot, respectively. Evaluation of the incremental prognostic value of these markers was done by comparing the AUC between the old and new risk score, and the use of net reclassification improvement (NRI) and integrated discrimination improvement (IDI).
Among 192 total patients (median [IQR] age 56 [42-70] years; 114 [59.4%] women), there were 43 (22.4%) who did not survive to discharge. Of the novel inflammatory markers, only red cell distribution width to hemoglobin ratio was significant in predicting in-hospital mortality (odds ratio [OR] 3.55; 95% CI, 1.76-7.16; P < .001) after adjusting for SCORTEN. The RDW/Hb as applied in 4 risk groups showed similar discrimination to SCORTEN (AUC [95% CI]: RDW/Hb in 4 groups, 0.76 [0.69-0.84], vs SCORTEN, 0.78 [0.70-0.85], P = .89). When RDW/Hb was added to SCORTEN, the composite score Re-SCORTEN showed significantly better discrimination than SCORTEN alone (AUC [95% CI]: Re-SCORTEN, 0.83 [0.77-0.89], vs SCORTEN, 0.78 [0.70-0.85], P = .02). The overall NRI was 0.94 (95% CI, 0.68-1.20), P < .001. The IDI was 0.06 (95% CI 0.03-0.08), P < .001. Re-SCORTEN showed good calibration based on the calibration plot.
In this cohort of patients, RDW/Hb, an inexpensive and readily available marker, showed similar predictive accuracy with SCORTEN. Furthermore, when used in combination with SCORTEN, it also helped augment prognostic ability.
表皮坏死松解症是一种严重的皮肤不良反应，其中严重的全身炎症导致广泛的上皮角质形成细胞坏死。在表皮坏死松解症中最常用的预后评分，即毒性表皮坏死松解症严重程度评分（SCORTEN），最近被发现高估了当代队列的死亡率。识别独立的预后标志物可能有助于更准确地分层风险。
本研究评估了新型炎症标志物与表皮坏死松解症患者院内死亡率之间的关系，以研究这些标志物与 SCORTEN 联合使用的增量预后价值。
设计、设置和参与者：这是一项回顾性队列研究，在 2003 年至 2019 年期间进行了 17 年。从新加坡总医院招募了患有表皮坏死松解症的患者，该医院是表皮坏死松解症的国家转诊中心。共招募了 196 名患有表皮坏死松解症的患者，其中 4 名（2%）因数据不完整而被排除在外。
主要评估的结果是院内死亡率。使用接受者操作特征曲线（ROC）下面积（AUC）和校准图分别评估风险评分的区分度和校准度。通过比较新旧风险评分之间的 AUC 来评估这些标志物的增量预后价值，并使用净重新分类改善（NRI）和综合判别改善（IDI）。
在 192 名总患者中（中位数[IQR]年龄 56[42-70]岁；114[59.4%]为女性），有 43 名（22.4%）未存活至出院。在新型炎症标志物中，只有红细胞分布宽度与血红蛋白比值在调整 SCORTEN 后对预测院内死亡率有显著意义（比值比[OR]3.55；95%CI，1.76-7.16；P<0.001）。在 4 个风险组中应用 RDW/Hb 与 SCORTEN 具有相似的区分度（AUC[95%CI]：RDW/Hb 在 4 个组中，0.76[0.69-0.84]，SCORTEN 为 0.78[0.70-0.85]，P=0.89）。当 RDW/Hb 加入 SCORTEN 后，复合评分 Re-SCORTEN 与单独使用 SCORTEN 相比，具有显著更好的区分度（AUC[95%CI]：Re-SCORTEN，0.83[0.77-0.89]，SCORTEN 为 0.78[0.70-0.85]，P=0.02）。总体 NRI 为 0.94（95%CI，0.68-1.20），P<0.001。IDI 为 0.06（95%CI 0.03-0.08），P<0.001。根据校准图，Re-SCORTEN 显示出良好的校准度。
在本队列研究中，RDW/Hb 是一种廉价且易于获得的标志物，其预测准确性与 SCORTEN 相似。此外，当与 SCORTEN 联合使用时，它还有助于提高预后能力。
