LAUSR

In an interesting cohort study of patients with Fournier’s gangrene by Dr Osbun and colleagues, there were no differences in mortality rates between patients treated at a high-volume center (7.0%) and those at low-volume centers (6.4%), despite higher rates of septic shock and respiratory failure at the high-volume center. The majority of patients treated at the high-volume center were transferred from low-volume centers, and immediate transfer of less than 1 day from initial presentation was associated with fewer surgical debridements and lower rates of septic shock and renal failure compared with delayed transfer. Accordingly, Osbun and colleagues suggest a benefit of immediate transfer for regionalized care of patients with Fournier’s gangrene. However, it would be impractical to transfer all the patients presenting at low-volume hospitals with symptoms suggestive of Fournier’s gangrene. Advanced Fournier’s gangrene and severe burn share some initial clinical features and consequences, including soft tissue infections, metabolic derangement, sepsis, and remote organ failure, and require multimodal management at specialized centers, such as level I/II trauma centers and burn centers, with 24-hour coverage by critical care, emergency medicine, anesthesiology, radiology, general surgery, plastic surgery, and microbiology laboratory. In a study using a national database of 10,940 patients with necrotizing soft tissue infections (necrotizing fasciitis, gas gangrene, and Fournier’s gangrene), about 13% of the patients were treated at burn centers. Given the availability of specialty care facilities, it would be reasonable to treat low-risk patients with mild to moderate burns at general hospitals, according to the American Burn Association (ABA) severity criteria. In a tertiary burn center, however, there was no need for transfer on the basis of the current medical condition in about 46% of 578 patients referred from another hospital, and 34% of the referral met the ABA criteria. Likewise, the mild form of Fournier’s gangrene could be safely treated in nonteaching hospitals. In a national study including 1,641 male patients with Fournier’s gangrene, treated at