Thrombotic microangiopathy in patients with malignant hypertension.

BACKGROUND: Thrombotic microangiopathy (TMA) is a complication of malignant hypertension (mHTN) attributed to high blood pressure (BP). However, no studies have investigated in patients with mHTN of different aetiologies whether the presence of TMA is associated with specific causes of mHTN. METHODS: We investigated the presence of TMA (microangiopathic haemolytic anaemia and thrombocytopenia) in a large and well-characterized cohort of 199 patients with mHTN of different aetiologies [primary HTN 44%, glomerular diseases 16.6%, primary atypical haemolytic uraemic syndrome (aHUS) 13.1%, renovascular HTN 9.5%, drug-related HTN 7%, systemic diseases 5.5%, endocrine diseases 4.5%]. Outcomes of the study were kidney recovery and kidney failure. RESULTS: Patients with TMA [40 cases (20.1%)] were younger, were more likely female and had lower BP levels and worse kidney function at presentation. Their underlying diseases were primary aHUS (60%), drug-related mHTN (15%), glomerular diseases [all of them immunoglobulin A nephropathy (IgAN); 10%], systemic diseases (10%) and primary HTN (5%). The presence of TMA was 92.3% in primary aHUS, 42.9% in drug-related HTN, 36.4% in systemic diseases, 12.1% in glomerular diseases and 2.3% in primary HTN. No patient with renovascular HTN or mHTN caused by endocrine diseases developed TMA, despite BP levels as high as patients with TMA. A higher proportion of TMA patients developed kidney failure as compared with patients without TMA (56.4% versus 38.9%, respectively). CONCLUSIONS: The presence of TMA in patients with mHTN should guide the diagnosis towards primary aHUS, drug-related mHTN, some systemic diseases and IgAN, while it is exceptional in other causes of mHTN.

Desarterialización en la hemorragia obstétrica: ligadura de hipogástricas, ováricas, Sampson. Seguimiento por angiotomografía computada pélvica / Dearterialization against obstetric hemorrhage: hypogastric -ovarian ligation- Sampson follow-up by pelvic computed tomography angiography

Resumen OBJETIVO: Describir la técnica Ramírez-Maksymenko (ligadura de arterias hipogástricas, ováricas, Sampson) y mostrar que la angiotomografía computada pélvica inmediata favorece la disminución de la morbilidad y mortalidad materna por hemorragia obstétrica. MATERIALES Y MÉTODOS: Estudio prospectivo efectuado entre los meses de mayo de 2019 a marzo de 2020. Se incluyeron pacientes con hemorragia obstétrica postoperadas con la técnica Ramírez-Maksymenko, con seguimiento por angiotomografía computada pélvica y observación de las principales arterias que irrigan al útero, conforme al tiempo posterior a la cirugía hasta retornar a la normalidad. RESULTADOS: Se estudiaron 5 pacientes que en la angiotomografía computada pélvica posoperatoria se encontraron con adecuada vascularidad uterina por las arterias: sacra media, iliolumbares, vaginales y ováricas. Todas las pacientes retornaron a la normalidad aproximadamente a los 3 meses 14 días. El diámetro de las hipogástricas al día siguiente del posoperatorio fue de 1 mm y a los 3 meses 14 días de 4 mm (normal). CONCLUSIONES: Con esta técnica se evitan transfusiones masivas, ingreso a terapia intensiva; además, disminuye la vascularidad uterina y se favorece el más rápido retorno a la normalidad. Con esta técnica de desarterialización, el útero continúa con adecuada vascularidad por las arterias iliolumbares, sacras medias, vaginales y ramas de las arterias ováricas, a pesar de encontrarse ligadas, lo que debe suceder con otras técnicas quirúrgicas donde se ligan. Una sola seda 1 o hilo crómico del 2-0 es suficiente para disminuir el diámetro de las hipogástricas; algunas técnicas utilizan dos suturas. En 3 meses 14 días, aproximadamente, la circulación regresa a la normalidad.

Abstract OBJECTIVE: To describe the Ramírez-Maksymenko technique (ligation of hypogastric, ovarian, Sampson arteries) and show that immediate pelvic computed tomography angiography favors the decrease in maternal morbidity and mortality due to obstetric hemorrhage. MATERIALS AND METHODS: Prospective study carried out between the months of May 2019 to March 2020. Patients with obstetric hemorrhage postoperated with the Ramírez-Maksymenko technique were included, with follow-up by pelvic computed tomography angiography and observation of the main arteries supplying the uterus, according to the time after surgery until returning to normal. RESULTS: Five patients were studied who, on postoperative pelvic computed tomography angiography, found adequate uterine vascularity through the arteries: medial sacral, iliolumbar, vaginal, and ovarian arteries. All patients returned to normal at approximately 3 months 14 days. The diameter of the hypogastric patients the day after the postoperative period was 1 mm and at 3 months 14 days 4 mm (normal). CONCLUSIONS: With this technique, massive transfusions, admission to intensive care, reduction of uterine vascularity are avoided, and a faster return to normal is favored.With this dearterialization technique, the uterus continues with adequate vascularity through the iliolumbar, middle sacral, vaginal, and branches of the ovarian arteries, despite being linked, which should happen with other surgical techniques where they are ligated. A single silk 1 or 2-0 chromic thread is sufficient to decrease the diameter of the hypogastric; some techniques use two sutures. In approximately 3 months and 14 days, the circulation returns to normal.

Understanding variations in the use of hypofractionated radiotherapy and its specific indications for breast cancer: A mixed-methods study.

BACKGROUND AND PURPOSE: Radiation oncology guidelines favour hypofractionated whole-breast radiotherapy (HWBRT) over more conventional schemes in the conservative treatment of breast cancer, but its adoption still varies in clinical practice. This study assessed the patterns of HWBRT adoption in Catalonia (Spain). MATERIAL AND METHODS: We used a mixed-methods approach based on an explanatory sequential design, first collecting and analysing quantitative data on HWBRT use (>2.5Gy per fraction) in 11 public radiotherapy centres (2005-2015) and then performing 25 semi-structured interviews with all department heads and reference radiation oncologist/s. RESULTS: Of the 34,859 patients fulfiling the study criteria over the study period, just 12% were hypofractionated, reaching a percentage of 29% in 2015 (p<0.001). Our analysis showed a narrowing age gap between patients receiving conventional fractionation and hypofractionation in centres leading adoption. However, there were important differences in clinicians' interpretation of evidence (e.g. regarding the perceived risk of long-term toxicity) and selection of patients for specific indications, both within and between departments. CONCLUSIONS: Differences observed in the rate of adoption of HWBRT could not be tackled only using a rational, evidence-based approach. Factors related to the management of radiotherapy departments play a major role in the diffusion of therapeutic strategies.