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We were interested to read the series of articles on the efficacy of intravenous immunoglobulin (IVIG) for the treatment of toxic epidermal necrolysis (TEN), published in the January issue of ARCHIVES. Most reports of trials of therapy in TEN are case series with no control group and so are difficult to interpret. The articles by Trent et al1 and Bachot et al2 address this by comparing actual mortality of IVIG-treated patients with mortality predicted by the SCORTEN prognostic scoring index.3
SCORTEN was developed using a sample of 165 patients and logistic regression analysis to identify independent risk factors for mortality. Seven factors were identified and given equal weighting in the score. Probability of death is calculated from the score. Probability of death = elogit /1 + elogit, where logit = −4.445 + 1.237 (TEN score). The SCORTEN was validated on a sample of 75 patients using measures of calibration and discrimination and was found to show good agreement.
We note that in the articles by Trent et al and Bachot et al the numbers used for predicted mortality are in fact the actual mortality of the patient sample used to develop the SCORTEN. Mortality predictions should have been calculated using the probability of death equation.
Trent et al report an improved mortality in patients treated with IVIG. They report a series of 16 patients, with 1 death. They compare this with an expected mortality of 5.81 rather than the figure of 5.52 calculated from the model. The difference between these 2 numbers is small but it is important to note for future studies that predicted mortality should be calculated as devised in the original SCORTEN article rather than taken from the actual mortality of the development sample.
The significance of Trent et al's findings is uncertain. Bachot et al found no significant difference in mortality for patients treated with IVIG at the Hopital Henri-Mondor in France, which is the institute where the SCORTEN was developed. The improved survival in the series of Trent et al when compared with predicted SCORTEN might reflect factors such as the ethnic mix among their patients, the etiology of TEN, or local management strategies rather than the use of IVIG.
The SCORTEN is a useful tool when used properly. It may have a role in assessing the effect of any therapeutic intervention in TEN although it should be validated as a prognostic score in different populations. It is clear that, while helpful, it is not an adequate substitute for a controlled trial.
The authors have no relevant interest in this letter.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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