Supportive care in the acute phase of Stevens-Johnson syndrome and toxic epidermal necrolysis: an international, multidisciplinary Delphi-based consensus.

BACKGROUND: Supportive care is the cornerstone of management of adult and paediatric Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). However, consensus on the modalities of supportive care is lacking. OBJECTIVES: Our aim in this international multicentric Delphi exercise was to establish a multidisciplinary expert consensus to standardize recommendations regarding supportive care in the acute phase of SJS/TEN. METHODS: Participants were sent a survey via the online tool SurveyMonkey, consisting of 103 statements organized into 11 topics: multidisciplinary team composition, suspect drug management, infection prevention, fluid resuscitation and prevention of hypothermia, nutritional support, pain and psychological distress management, management of acute respiratory failure, local skincare, ophthalmological management, management of other mucosa, and additional measures. Participants evaluated the level of appropriateness of each statement on a scale of 1 (extremely inappropriate) to 9 (extremely appropriate). The results were analysed according to the RAND/UCLA Appropriateness Method. RESULTS: Forty-five participants from 13 countries (on three continents) participated. After the first round, a consensus was obtained for 82.5% of the 103 initially proposed statements. After the second round, a final consensus was obtained for 102 statements. CONCLUSIONS: We have reached an international Delphi-based consensus on best supportive care practice for SJS/TEN. Our expert consensus should help guide physicians in treating patients with SJS/TEN and thereby improve short-term prognosis and the risk of sequelae.

Catastrophes Liées À Une Explosion De Camionciterne Entre 2000 Et 2020. Deux Groupes Distincts.

Incidents involving tanker trucks regularly appear in the media. The one in Morogoro (Tanzania) on August 10th 2019 (killing at least 89) attracted our attention. We reviewed medical literature (sparse) and media reports to identify and analyse these incidents. In high income countries isolated accidents may be responsible for a few deaths. In low income countries "double" accidents can occur. A commonplace incident occurs which frequently has no victim. When the incident involves a petrol leak, people gather to scoop up the fuel. A spark ignites the petrol and the ensuing engulfing fire is in itself deadly. Frequently, it triggers a tanker BLEVE, which is responsible for a disaster. Preventing these casualties should include avoiding the initial incident, and also (and above all) discouraging the locals from scooping up fuel they can use or possibly sell in order to survive.

[Hospitalisations Related To Burns In France. Analyses Of 2019's National Data Base]. / Hospitalisations Pour Brûlure En France. Données 2019 Extraites De La Base PMSI Nationale.

Thanks to the Medical Information Service of our institution, we obtained the data on burns during 2019, saved in the national database. We found 10,913 reports, among them 10,347 metropolitan and 566 overseas. When compared to the French population on January 1st 2020, the incidences were 16 (global population); 15.7 (metropolitan) and 27.1 (overseas)/100,000 inhabitants respectively. The majority (62.95%) of the patients were taken care of in Burn Centres (BCs). However, 4,043 patients were never seen by a burn specialist. Nevertheless 88.54% of skin grafts were performed in BCs and 71.86% of the burns with high seriousness (levels 3 and 4) were in BCs. One hundred and seventy-nine patients (1.64%) died. For the first time, we obtained the intensive care activity, through the scoring actions. Intensive care was held for 958 patients (8.96%), 90.81% of them in a BC. Only 28.57% were associated with major (>30% BSA) burns, but these major burns accounted for 63.78% of the organ failure treatments.

[Antimicrobial blood concentrations in burns. A five years' retrospective survey]. / Concentrations sanguines d'antibiotiques chez les patients brûlés. Etude rétrospective sur cinq ans.

The monitoring of antimicrobial agents is a routine in our unit. We reviewed the results either of peak-and-through concentrations (peak and through is one sample) or concentrations at steady state (Css) of all antimicrobials given over five years (2001 to 2005) and studied the antimicrobials with at least 20 samples. We found 706 samples in 122 patients, the antimicrobials being amikacin, amoxicillin, ceftazidime, ciprofloxacin, cloxacillin, gentamicin, imipenem, ofloxacin, tobramycin and vancomycin. When comparing samples in witch the concentrations were above a value thought to be predictive of efficacy to those were not, we could notice: that no parameter about patients or burn surface was predictable for achieving targeted blood concentration; that usual regimen could not achieve targeted concentrations, excepted with ceftazidime, provided it was used in continuous infusion; that, with the other beta-lactams, continuous infusion was more likely to achieve targeted blood concentrations; that, with fluoroquinolones, both higher and more frequent injections were needed; that, with aminoglycosides used once a day, the dosage had to be higher than usually recommended. We conclude that antimicrobial regimen should be altered in burns and that a monitoring of blood concentrations should be performed in these patients.

[Pharmacokinetic evaluation of linezolid in patients with major thermal injuries]. / Pharmacocinétique du linézolide chez des patients souffrant de brûlures sévères.

The aims of this multicentre open-label study was to evaluate the pharmacokinetics of linezolid in patients with burn injury above 20 % BSA and to compare them with healthy volunteers, matched in age, sex and weight. After a single 600 mg IV dose of linezolid, multiple blood and urine samples were taken from subjects, in order to determine linezolid concentrations, using a HPLC assay. C(max) and volume of distribution at steady state were not different between the two groups. Values describing clearance were altered in burns, leading to a reduction by half in AUC in these patients (42.5 versus 98.1 mghL(-1)). The enhancement of clearance was due to which of non renal clearance (323+/-191 versus 80.4+/-27.5 mLmin(-1)). We conclude that pharmacokinetics of linezolid are altered in burn patients, in a magnitude sufficient that linezolid concentration may be subtherapeutic in some patients and we suggest that the dosage interval may need to be decreased in this patient population.

Pharmacokinetic evaluation of linezolid in patients with major thermal injuries.

AIMS: To evaluate the pharmacokinetics of linezolid following its administration in patients with major thermal injuries and in a group of healthy volunteers. METHODS: In an open-label, multicentre design with two parallel groups, a group of patients with major thermal injuries (>20% body area) and a group of age-, sex- and weight-matched healthy volunteers, subjects received a single 600 mg intravenous dose of linezolid. Serial blood and urine collections were made and the concentrations of linezolid in these samples were determined by HPLC. Non-compartmental analyses were used to describe the pharmacokinetic disposition of linezolid. RESULTS: C(max) concentrations and the volume of distribution at steady state (V(ss)) were not statistically different (P > 0.05) between the two groups of subjects. In contrast, values describing clearance [elimination rate constant (k(el)), t(1/2) and mean residence time (MRT)] were significantly different (P < 0.05) in patients with thermal injuries compared with volunteers, which lead to an approximate reduction by half in AUC(0-infinity) from 98.1 mg.h/L (volunteers) to 42.5 mg.h/L (patients). Although renal clearance was similar in the two groups (24.7 +/- 23 versus 30.6 +/- 14.3 mL/min; P = 0.156), non-renal clearance was substantially increased (323 +/- 191 versus 80.4 +/- 27.5 mL/min) in the patients with thermal injuries, though this difference did not achieve statistical significance (P = 0.063). CONCLUSIONS: The pharmacokinetics of linezolid are altered in patients with major thermal injuries, mainly as a result of increased non-renal clearance. These changes are of sufficient magnitude that linezolid concentrations may be sub-therapeutic in some patients and we suggest that the dosage interval may need to be decreased in this patient population.

Résumé Des Tables Rondes Du 39ème Congrès De La SFB.

This congress shared 3 main topics: inflammation - especially in the rehabilitation phase, fires and smoke inhalation, and flaps in sequelae. The first is reported by Valérie Chauvineau, the second by Ronan Le Floch and the third by Louise Pasquesoone.

Catastrophes et brûlologie.

Traumatology is an old specialty, and most knowledge about it was developed during wars. On the other hand, burn care is much more recent and knowledge has been acquired in particular from civilian disaster casualties. This paper aims to describe some of the disasters that led to progress in burn care.

Utilisation précoce de l'irm pour l'évaluation du niveau d'amputation des membres dans la prise en charge des brûlures électriques à haute tension.

High-voltage electrical burns are rare, but the functional prognosis is often disastrous. Electrical currents are responsible for a wide range of injuries and their clinical assessment is difficult. For a case of severe electrical burn, and based on the literature, the authors performed an early MRI to elaborate their surgical strategy and avoid multiple surgeries by determining the level of amputation. Analysis of the different MRI signals and the per-operative study of the tissues led the team to take an early surgical approach and we were able to determine the level of limb amputation. Early analysis of lesions by MRI imaging allows us to consider a more aggressive surgical approach and thus reduce the number of interventions and the duration of stay in the intensive care unit.

Selective inhibition of MEK1/2 reveals a differential requirement for ERK1/2 signalling in the regulation of HIF-1 in response to hypoxia and IGF-1.

The transcription factor hypoxia-inducible factor 1 (HIF-1) plays a pivotal role in tumour growth and progression, and HIF-1 is regulated through a number of signalling pathways. Here, we investigated the involvement of the mitogen-activated protein kinase (MAPK) signalling pathway in HIF-1 regulation. We found that overexpression of wild-type (WT) extracellular signal regulated protein kinase 1 (ERK1) greatly potentiated HIF-1 activation in hypoxia and HIF-1alpha induced in response to insulin growth-like factor 1 (IGF-1). Conversely, treatment of tumour cells with the MEK1/2 inhibitors PD98059 or U0216, or expression of a dominant-negative form of ERK1 blocked HIF-1 activation in hypoxia without affecting HIF-1alpha induction, localization or binding of HIF-1beta. Interestingly however, the highly selective MEK1/2 inhibitor PD184352 did not inhibit HIF-1 activity or vascular endothelial growth factor (VEGF) induced in response to hypoxia but blocked HIF-1alpha protein and HIF-1 activity induced by IGF-1 stimulation without affecting HIF-1alpha mRNA levels. Finally, we found that ERK5 phosphorylation status was not significantly affected by hypoxia in the presence or absence of PD184352. Taken together, our data suggest that although ERK1/2 signalling is important for HIF-1alpha induction and HIF-1 activity in response to IGF-1, it is dispensable for the induction of HIF-1alpha and activation of HIF-1 in response to hypoxia.

[Free-flap reconstruction in the elderly patient]. / La reconstruction par lambeau libre chez le sujet âgé

The objective of the study was to evaluate the safety and the efficacity of microsurgery in the elderly patient population. Between 2003 and 2005, 10 free-flaps were performed in 10 patients who were aged 70 years or older. One flap underwent reexploration, for an overall success rate of 100%. Medical complications in the postoperative period were further evaluated. Effects of American Society of Anesthesiologists (ASA) status, operation time, and age on complication rate were evaluated. Only ASA status was significant for the occurrence of postoperative medical complications; class 3 and 4 patients were at higher risk than class 1 and 2. Neither operation time nor age was predictive of postoperative complications. Microvascular free-tissue transfer is a safe and reliable option in the elderly population. The success rate of free-flaps is not different from that for other age groups. The rate of postoperative medical complications was 20%: most complications were in ASA class 3 and 4 patients.

Compte-rendu des tables rondes, jeudi 7 juin 2018, 38ème congrès de la SFB, Lille.

The 2018 topics were « burns to the upper limb, hand excluded ¼ and « advances in analgesia and sedation ¼. The authors used both the notes they took during the session and video footage to write this report. The reader should get in touch with the lecturer if more in-depth information is required.

Résumés de la table ronde du 37ème Congrès De La SFB, 8 Juin 2017.

The main topic of the 2017 SFB congress was « burn and infections ¼. It took place on Thursday, 8th June. Twenty presentations were given, and this article illustrates each of them. The authors are listed above and the title of each paragraph is the title of their presentation.

Le ciment brûle toujours.

Cement burn is a common cause of chemical burns in France. They usually need surgical treatment. This retrospective study was performed among 49 patients, aged 21-71 years, admitted to the St Joseph-St Luc Hospital in Lyon, France. Patients were mainly male, fairly young (mean 44 years) and had a professional activity, although burns usually occurred at home. Burns were deep, on the lower limbs, and were not extensive (3% TBS). All but one patient needed grafting, performed on d13. LOS was eight days. Seven patients had to be admitted to a rehabilitation centre afterwards. This study confirms the local seriousness of cement burns. It emphasises their socio-economic impact since they occur in job-active patients. Education on cement hazards should be developed, targeting this population, who are seldom building professionals. Current regulations, classifying cement as an 'irritant', do not address the causticity of wet cement and should be amended.

[Unusual haemostasis disorder in a seriously burned patient]. / Trouble inhabituel de l'hémostase au cours d'une brûlure grave.

We report the case of a woman severely burned during a gas explosion with an unusual disorder of haemostasis. The prothrombin time was very elevated, essentially by a drop in factor II. This abnormality persisted for a long time after the correction of the dilutional and consumption coagulopathy which followed immediately the burn. Blood analysis found fluindione and benzodiazepine derivatives. Such a disorder during a potentially suicidal burn must evoke a toxic aetiology.

Compte rendu de la table ronde du 36ème Congrès de la SFB à Cassis (1-3 Juin 2016), première partie: brûlures chimiques, brûlures électriques.

The 2016 SFB congress focused on 'non-thermal burns', and this session lasted the whole day of Thursday 2nd June. While the reports on radiation-induced burns are currently being prepared by the presenters themselves, this paper on chemical and electrical burns was put together by the above-mentioned authors using notes taken during the session and video of the presentations. Any reader desiring further information on a topic can contact the author of the relevant presentation directly.

[Not Available]. / Infections fongiques des brûlé : revue.

Local or general fungal infection remain a very serious event in burns. Burns have numerous risk factors for such, infections associated with depressed immunity. Candida, Aspergillus and mucor fungi prevail in wound infections. The two latest are especially serious and impairing. Diagnosis is based on anatomo-pathological and mycological examination of skin samples. Treatment is mainly surgical. Medical therapy depends on antifungal susceptibility. Most fungemias are candidemias. Diagnosis is difficult and often based on clinical suspicion. Treatment uses echinocandin and fluconazole.

35ème congrès SFB, table ronde «nutrition¼: transcription des communications.

Chaque année, le congrès de la SFB est l'occasion d'une mise au point sur un thème (« table ronde ¼.) Celui choisi en 2015 était la nutrition. Huit orateurs se sont succédés, faisant le point sur les données actuelles de la science, les pratiques dans les centres, et les recommandations actuelles, datant de 2013. Cet article se propose de diffuser les interventions.