Radiation-Induced Leiomyosarcoma after Breast Cancer Treatment and TRAM Flap Reconstruction

The development of a radiation-induced sarcoma (RIS) in the post mastectomy thoracic treatment volume is an infrequent, but recognized, event. Its frequency is rising in relation with increasing survival of breast cancer patients treated with adjuvant radiation therapy, and is associated with poor prognosis despite treatment. We present a case of leiomyosarcoma in a patient who underwent mastectomy followed by radiotherapy for invasive ductal carcinoma. A delayed TRAM flap reconstruction was performed 10 years after and a rapid growing mass under the reconstructed flap appeared, on routine follow-up, twenty years later. This report analyzes the diagnostic and therapeutic approach of patients with RIS

Nurses' perceptions of aids and obstacles to the provision of optimal end of life care in ICU

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Impact of dialysis modality on morbimortality of kidney transplant recipients after allograft failure. Analysis in the presence of competing events

Background and objective: The number of patients who start dialysis due to graft failure increases every day. The best dialysis modality for this type of patient is not well defined and most patients are referred to HD. The objective of our study is to evaluate the impact of the dialysis modality on morbidity and mortality in transplant patients who start dialysis after graft failure. Material and methods: A multicentre retrospective observation and cohort study was performed to compare the evolution of patients who started dialysis after graft failure from January 2000 to December 2013. One group started on PD and the other on HD. The patients were followed until the change of dialysis technique, retransplantation or death. Anthropometric data, comorbidity, estimated glomerular filtration rate (eGFR) at start of dialysis, the presence of an optimal access for dialysis, the appearance of graft intolerance and retransplantation were analyzed. We studied the causes for the first 10 hospital admissions after starting dialysis. For the statistical analysis, the presence of competitive events that hindered the observation of the event of interest, death or hospital admission was analyzed. Results: 175 patients were included, 86 in DP and 89 in HD. The patients who started PD were younger, had less comorbidity and started dialysis with lower eGFR than those on HD. The mean follow-up was 34 ± 33 months, with a median of 24 months (IQR 7–50 months), Patients on HD had longer follow-up than patients on PD (35 vs. 18 months, p = < 0.001). The mortality risk factors were age sHR 1.06 (95% CI: 1.03–1.106, p = 0.000), non-optimal use of access for dialysis sHR 3.00 (95% CI: 1.507–5.982, p = 0.028) and the dialysis modality sHR (PD/HD) 0.36 (95% CI: 0.148−0.890, p = 0.028). Patients on PD had a lower risk of hospital admission sHR [DP/HD] 0.52 (95% CI: 0.369−0.743, p = < 0.001) and less probability of developing graft intolerance HR 0.307 (95% CI 0.142−0.758, p = 0.009). Conclusions: With the limitations of a retrospective and non-randomized study, it is the first time nationwide that PD shows in terms of survival to be better than HD during the first year and a half after the kidney graft failure. The presence of a non-optimal access for dialysis was an independent and modifiable risk factor for mortality. Early referral of patients to advanced chronic kidney disease units is essential for the patient to choose the technique that best suits their circumstances and to prepare an optimal access for the start of dialysis. Resumen: Antecedentes y objetivo: El número de pacientes que inician diálisis por fracaso del injerto aumenta cada día. La modalidad de diálisis mejor para este tipo de pacientes no está bien definida y la mayoría de pacientes son derivados a HD. El objetivo de nuestro estudio es evaluar el impacto de la modalidad de diálisis sobre la morbilidad y la mortalidad en pacientes trasplantados que inician diálisis tras fracaso del injerto. Material y métodos: Estudio multicéntrico retrospectivo osbervacional y de cohortes que compara la evolución de pacientes que inician diálisis tras fracaso del injerto desde enero de año 2000 a Diciembre de 2013. Un grupo lo hace en DP y otro en HD. Se siguieron los pacientes hasta el cambio de técnica de diálisis, retrasplante o fallecimiento. Se analizaron datos antropométicos, comorbilidad, el filtrado glomerular (FG) con el que iniciaban diálisis, la presencia de un acceso óptimo para diálisis, la presencia de intolerancia al injerto y el retrasplante. Estudiamos el motivo de los 10 primeros ingresos hospitalarios tras el inicio de diálisis. Para el análisis estadístico se tuvo en cuenta la presencia de eventos competitivos que dificultaran la aparición del evento de interés muerte o ingreso hospitalario. Resultados: Se incluyeron 175 pacientes. 86 en DP y 89 en HD. Los pacientes que iniciaron DP eran mas jóvenes, tenían menor comorbilidad y lo hacían con FG más bajos que los de HD. El seguimiento medio fue de 34 ± 33 meses, con una mediana de 24 meses (RIQ 7–50 meses), siendo mayor en los pacientes en HD que en los de DP (35 vs 18 meses, p = < 0,001). Los factores de riesgo que influyeron en la mortalidad fueron, la edad (sHR 1,06 (IC 95 %: 1,033−1,106, p = 0,000), el uso no óptimo del acceso (sHR 3,00 (IC 95 %: 1,507−5,982, p = 0,028) y el tipo de diálisis, la DP sHR[DP/HD] 0,36 (IC 95 %: 0,148−0,890, p = 0,028). Los pacientes en DP tenían menos riesgo de tener un ingreso hospitalario sHR[DP/HD] 0,52 (IC 95 %: 0,369−0,743, p = <0001) y menos probabilidad de desarrollar una intolerancia al injerto HR 0307 (IC 95 % 0,142−0,758, p = 0.009). Conclusiones: Con las limitaciones de un estudio retrospectivo y no randomizado, es la primera vez a nivel nacional que se demuestra que la DP en términos de supervivencia es mejor que la HD cuando fracasa el injerto durante el primer año y medio en diálisis. La presencia de un acceso no óptimo para diálisis es un factor de riesgo de mortalidad independiente y modificable. La remisión precoz de los pacientes a las unidades de enfermedad renal crónica avanzada (ERCA) es fundamental para que el paciente elija la técnica que más se adapte a sus circunstancias y preparar un acceso óptimo para el inicio de diálisis

Chronic coronary syndromes without standard modifiable cardiovascular risk factors and outcomes: the CLARIFY registry

Background and Aims: It has been reported that patients without standard modifiable cardiovascular (CV) risk factors (SMuRFs—diabetes, dyslipidaemia, hypertension, and smoking) presenting with first myocardial infarction (MI), especially women, have a higher in-hospital mortality than patients with risk factors, and possibly a lower long-term risk provided they survive the post-infarct period. This study aims to explore the long-term outcomes of SMuRF-less patients with stable coronary artery disease (CAD). Methods: CLARIFY is an observational cohort of 32 703 outpatients with stable CAD enrolled between 2009 and 2010 in 45 countries. The baseline characteristics and clinical outcomes of patients with and without SMuRFs were compared. The primary outcome was a composite of 5-year CV death or non-fatal MI. Secondary outcomes were 5-year all-cause mortality and major adverse cardiovascular events (MACE—CV death, non-fatal MI, or non-fatal stroke). Results: Among 22 132 patients with complete risk factor and outcome information, 977 (4.4%) were SMuRF-less. Age, sex, and time since CAD diagnosis were similar across groups. SMuRF-less patients had a lower 5-year rate of CV death or non-fatal MI (5.43% [95% CI 4.08–7.19] vs. 7.68% [95% CI 7.30–8.08], P = 0.012), all-cause mortality, and MACE. Similar results were found after adjustments. Clinical event rates increased steadily with the number of SMuRFs. The benefit of SMuRF-less status was particularly pronounced in women. Conclusions: SMuRF-less patients with stable CAD have a substantial but significantly lower 5-year rate of CV death or non-fatal MI than patients with risk factors. The risk of CV outcomes increases steadily with the number of risk factors