ABSTRACT
BACKGROUND: Calciphylaxis (CPX) is a rare and life-threatening disease characterized by vascular calcification and development of painful and necrotizing skin lesions with a challenging management. Mechanisms of CPX are complex and include an imbalance between vascular calcification promoters and inhibitors, and frequently vitamin K deficiency. OBJECTIVES: To describe the various presentations and identify predictive factors of death in patients with CPX. METHODS: In this multicenter retrospective study, we included 71 CPX patients followed in South-West France (n = 26) and in French Polynesia (n = 45), and who all received sodium thiosulfate (25 g thrice weekly for a median of 61 days). RESULTS: Characteristics at presentation significantly differed between metropolitan and Polynesian French patients. Polynesians were less frequently on regular dialysis at the onset of CPX, had a higher incidence of diabetes mellitus and obesity, more disturbances of calcium-phosphorus metabolism, and received vitamin K antagonists less frequently than patients from South-West France. Despite intensive management, the 1-year mortality rate was 66% and median time to death was 200 days (IQR, 40; 514). The number of body areas involved (i.e., three: OR 2.70 [1.09; 6.65], p = 0.031; four: OR 8.79 [1.54; 50.29], p = 0.015) was the only predictive factor for death, whereas application of topical cerium nitrate-silver sulfadiazine was protective (OR 0.44 [0.20; 0.99], p = 0.046). Surgical debridement, hyperbaric oxygenation therapy, and geographical origin were not associated with overall outcomes. CONCLUSIONS: Cerium nitrate may lead to vascular decalcification and chelation of reactive oxygen species, and prevent infection. Cerium nitrate-silver sulfadiazine was associated with better outcomes and should be tested in a prospective comparative trial in CPX patients.
Subject(s)
Anti-Infective Agents, Local/therapeutic use , Calciphylaxis/therapy , Cerium/therapeutic use , Silver Sulfadiazine/therapeutic use , Skin Diseases, Vascular/drug therapy , Administration, Cutaneous , Aged , Anti-Infective Agents, Local/administration & dosage , Calciphylaxis/etiology , Cerium/administration & dosage , Chelating Agents , Drug Combinations , Female , France , Humans , Kidney Failure, Chronic/complications , Kidney Failure, Chronic/therapy , Male , Middle Aged , Polynesia , Renal Dialysis , Retrospective Studies , Risk Factors , Silver Sulfadiazine/administration & dosage , Skin Diseases, Vascular/etiology , Survival Rate , Thiosulfates/therapeutic use , Treatment OutcomeABSTRACT
AIM: The aim of this study was to compare the clinical outcomes of different treatment strategies for children with partial-thickness scalds at two burn centers. At the first burn center, these burns were treated with a hydrofiber dressing (Aquacel®, Convatec, Inc.®, Princeton, NJ, USA) or silver sulfadiazine (SSD, Flammazine®, Sinclair IS Pharma, London, UK Pharmaceuticals), while at the second burn center, cerium nitrate-silver sulfadiazine (CN-SSD, Flammacerium®, Sinclair IS Pharma, London, UK Pharmaceuticals) was used. METHODS: A two-center retrospective study was conducted of children admitted between January 2009 and December 2013 for partial-thickness scalds up to 10% TBSA who were treated primarily with a hydrofiber dressing or silver sulfadiazine (Burn Center Rotterdam) vs. cerium nitrate-silver sulfadiazine (Burn Center Groningen). The Dutch Burn Repository R3 and the electronic medical records of the study population were used for data extraction. The primary outcome was the time to wound healing. The secondary outcomes were the length of hospital stay, wound infection, and surgical treatment. RESULTS: The time to wound healing differed between the groups (HR=1.46, 95%CI 1.17-1.82); the shortest time to wound healing was observed in the patients treated with CN-SSD (median 13 days), compared with 15 days for the patients treated with hydrofiber and 16 days for the patients treated with SSD (p<0.01). The length of stay was significantly shorter for the hydrofiber patients (medians: hydrofiber 3 days, SSD 10 days and CN-SSD 7 days; p<0.01), but their outpatient treatment period was significantly longer (medians: hydrofiber 12 days, SSD 6 and CN-SSD 4 days; p<0.01). The proportion of surgeries and the mean time to surgery was similar between the burn centers. CONCLUSIONS: This study compared different burn centers' treatment strategies for children with partial-thickness scalds and found a shorter time to wound healing in the CN-SSD group. Patients treated with hydrofiber had a shorter clinical period in comparison with the SSD and CN-SSD patients. The results of CN-SSD are promising and warrant further study. A prospective study is needed to gain full insight into the merits and drawbacks of the treatment strategies. This will allow clinicians to make full use of the strengths of particular treatments to benefit specific patients.