Serum bicarbonate as a marker to predict mortality in toxic epidermal necrolysis.

BACKGROUND: Toxic epidermal necrolysis (TEN) is a rare life-threatening disorder characterized by extensive epidermal necrolysis. Its mortality which varies from 20% to 60% is related to risk factors such as age, extent of epidermal detachment, and base deficit. OBJECTIVES: The purpose of this study is to investigate the risk factors of mortality in our patients with TEN. PATIENTS AND METHODS: From the year 2000 to 2006, the patients with TEN admitted to the National Taiwan University Hospital Burn Center were studied retrospectively using chart review. Eleven potential risk factors including age, gender, underlying disease, malignancy, extent of epidermal detachment, tachycardia, serum urea, glucose, base deficit, leucopenia, and intravenous infusion of immunoglobulin (IVIG) were analyzed. Patients were grouped into survivors (n » 11) and nonsurvivors (n » 5) after intensive care treatment. Logistic regression was used in multivariate analysis for identifying important predictors of mortality. RESULTS: The mean age of the patients with TEN was 58 years, while the mean total body surface area of epidermal necrolysis was 66.3%. The overall mortality rate was 31.3%. Among the potential risk factors, only serum bicarbonate <20 mmol/L was found to have significant association with mortality (P » .0128) in our patients with TEN. The odds of mortality in the patients with TEN having serum bicarbonate <20 mmol/L was 40 times higher than those without. CONCLUSION: This study has shown that serum bicarbonate <20 mmol/L is the most important risk factor of mortality in our patients with TEN and it may be used as a marker to predict hospital mortality.

Quantitative relationship between vascular kinking and twisting.

A wide variety of factors causing vascular thrombosis in the microvascular free flap reconstruction have been encountered. The most frequent situation in our experiences has been vascular kinking because of improper positioning. It has been reported that the best way to avoid kinking is to place the vessels at a neutral axis. However, curving the pedicles to match the recipient vessels cannot be avoided, especially in head and neck reconstruction with a large flap and long pedicle. According to our clinical experiences, the curved vascular pedicle needs rotation in its axis from the neutral position to avoid kinking. Furthermore, we noted that the number of loops equals the number of axial rotations of 360°. We propose that these experiences and ideas can have wide applications in various fields of vascular surgery.

Reconstruction for sternal osteomyelitis at the lower third of sternum.

BACKGROUND: Sternal wound infection causes considerable morbidity and mortality for open-heart patients. Treatment of the wounds at the upper two-thirds is easier with pectoralis major muscle or other flaps. However, there would be more problems with the lower one-third sternal wounds. METHODS: From 1983 to 2007, 32 patients of osteomyelitis involving the lower sternum were treated with one of the following methods: (1) Latissimus dorsi with fasciocutaneous extension flap (2) Tri-pedicled pectoralis major musculocutaneous flap (3) Pectoralis major muscle with rectus abdominis muscle flap (4) Pectoralis major muscle with omentum flap (5) Free vastus lateralis muscle flap and skin grafting RESULTS: The viability of these flaps was good except for one of the five patients with pectoralis major-rectus abdominis muscle. One of the patients from the free vastus lateralis muscle group died of heart failure 6 weeks after surgery, but the coverage of sternal wound was successful. No recurrent sternal infection was found. CONCLUSIONS: For coverage of sternal wounds, the transferred tissue must have optimal blood supply in order to overcome the infection. According to the descending degree of ease, the ladder of reconstruction is from (1) to (5), depending on the relative length of the sternal wound and the arc of rotation of these flaps. In pectoralis major with rectus abdominis flap group, it is suggested that the upper sternal wound be covered with pectoralis major muscle but lower third sternal wounds with omentum instead of rectus abdominis muscle.

The impact of open lung biopsy on diffuse pulmonary infiltrates in patients with AIDS.

The evidence concerning open lung biopsy (OLB) for diffuse pulmonary infiltrates in patients with AIDS is limited. This study retrospectively evaluated the diagnostic and therapeutic yields of OLB compared with bronchoscopy for patients with AIDS with diffuse pulmonary infiltrate treated in the National Taiwan University Hospital from 1997 to 2004. There were 15 and 46 patients enrolled in the OLB and bronchoscopic groups in this study, respectively. As compared with the bronchoscopic group, patients from the OLB group had a higher chance of acquiring a specific diagnosis and possible change of therapy (73 vs 32.6% and 60 vs 21.7%, respectively; P < 0.05). There were two (13.3%) patients with prolonged air leak (greater than 7 days) in the OLB group, whereas four patients (8.7%) had procedure-related complications in the bronchoscopic group. There was no procedure-related mortality in the OLB group. This study demonstrated that OLB can be safely performed in select patients and provide a superior diagnostic and therapeutic benefit compared with bronchoscopy for diffuse pulmonary infiltrates in patients with AIDS. This procedure should be performed early in the clinical course to avoid irreversible clinical deterioration of the patients with severe illness.