Spontaneous renal pelvic perforation in a patient with advanced lung cancer receiving avastin (bevacizumab). About a case. / Perforación espontánea de pelvis renal en paciente con cáncer de pulmón avanzado en tratamiento con avastin (bevacizumab). A propósito de un caso.

INTRODUCTION: Bevacizumab is a monoclonalantibody used as a targeted therapy in blocking vascularendothelial growth factor in different types of oncologicaland non-oncological diseases. It has demonstratedsurvival benefits in the treatment of many types of malignanttumors, including lung cancer. As all drugs have adverseeffects, one of the most uncommon being gastrointestinalperforation and few cases of ureteral stenosis. However,they do not mention or describe the perforation of segmentsof the urinary tract. OBJECTIVE: To describe renal pelvic perforation as an adverseeffect to the use of Bevacizumab. CASE DESCRIPTION: 67-year-old male patient with metastaticlung cancer being treated with Bevacizumab whohas perforation of the renal pelvis is presented. A pyelogramwas performed showing contrast extravasation at theleft renal pelvis and a double J catheter was placed, witha satisfactory clinical course, and tomographic control at 1month without evidence of extravasation of contrast, withdrawingdouble catheter J. CONCLUSION: Renal pelvic perforation secondary toBevacizumab is infrequent, but it must be taken into accountin patients treated with this drug.

INTRODUCCIÓN: Bevacizumab, es unanticuerpo monoclonal usado como terapia dirigida enbloqueo del factor de crecimiento endotelial vascular endiferentes tipos de enfermedades oncológicas y no oncológicas.Ha demostrado beneficios de supervivencia en eltratamiento de muchos tipos de tumores malignos, incluyendoel cáncer de pulmón. Como toda droga presenta efectosadversos, siendo uno de los más infrecuentes la perforacióngastrointestinal y pocos casos de estenosis ureterales.Sin embargo no mencionan ni describen la perforación desegmentos del tracto urinario. OBJETIVO: Describir la perforación de la pelvis renal comoefecto adverso al uso de Bevacizumab. DESCRIPCIÓN DE CASO: Se tiene paciente masculino de67 años con cáncer de pulmón metastático en tratamientocon Bevacizumab quien presenta perforación de pelvis surenal.Se realiza pielografía evidenciando extravasacióndel contraste a nivel de pelvis renal izquierda y se colocacatéter doble J, con evolución clínica satisfactoria, y controltomográfico al mes sin evidencia de extravasación delcontraste, retirándose catéter doble J. CONCLUSIÓN: La perforación de pelvis renal secundariaa Bevacizumab es infrecuente, pero hay que tenerla encuenta en pacientes tratados con este fármaco.

Impact of systolic blood pressure limits on the diagnostic value of triage algorithms.

BACKGROUND: Major incidents are characterized by a lack of resources compared to an overwhelming number of casualties, requiring a prioritization of medical treatment. Triage algorithms are an essential tool for prioritizing the urgency of treatment for patients, but the evidence to support one over another is very limited. We determined the influence of blood pressure limits on the diagnostic value of triage algorithms, considering if pulse should be palpated centrally or peripherally. METHODS: We used a database representing 500 consecutive HEMS patients. Each patient was allocated a triage category (T1/red, T2/yellow, T3/green) by a group of experienced doctors in disaster medicine, independent of any algorithm. mSTaRT, ASAV, Field Triage Score (FTS), Care Flight (CF), "Model Bavaria" and two Norwegian algorithms (Nor and TAS), all containing the question "Pulse palpable?", were translated into Excel commands, calculating the triage category for each patient automatically. We used 5 blood pressure limits ranging from 130 to 60 mmHg to determine palpable pulse. The resulting triage categories were analyzed with respect to sensitivity, specificity and Youden Index (J) separately for trauma and non-trauma patients, and for all patients combined. RESULTS: For the entire population of patients within all triage algorithms the Youden Index (J) was highest for T1 (J between 0,14 and 0,62). Combining trauma and non-trauma patients, the highest J was obtained by ASAV (J = 0,62 at 60 mmHg). ASAV scored the highest within trauma patients (J = 0,87 at 60 mmHg), whereas Model Bavaria (J = 0,54 at 80 mmHg) reached highest amongst non-trauma patients. FTS performed worst for all patients (J = 0,14 at 60 mmHg), showing a lower score for trauma patients (J = 0,0 at 60 mmHg). Change of blood pressure limits resulted in different diagnostic values of all algorithms. DISCUSSION: We demonstrate that differing blood pressure limits have a remarkable impact on diagnostic values of triage algorithms. Further research is needed to determine the lowest blood pressure value that is possible to palpate at a peripheral artery compared to a central artery. CONCLUSION: As a consequence, it might be important in which location pulses are palpated according to the algorithm at hand during triage of patients.