Corticosteroids for improving patient-relevant outcomes in HELLP syndrome: a systematic review and meta-analysis.

BACKGROUND: We conducted this updated systematic review to assess the effects of corticosteroids vs. placebo or no treatment for improving patient-relevant outcomes in hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome. METHODS: CENTRAL, MEDLINE/PubMed, Web of Science, and Scopus, from the date of inception of the databases to February 3, 2024 were searched. Reference lists of included studies and systematic reviews were thoroughly searched. We included RCTs that enrolled women with HELLP syndrome, whether antepartum or postpartum, to receive any corticosteroid versus placebo or no treatment. No language or publication date restrictions were made. We used a dual independent approach for screening titles and abstracts, full text screening, and data extraction. Risk of bias was assessed in the included studies using Cochrane's RoB 2 tool. Pairwise meta-analyses were conducted, where two or more studies met methodological criteria for inclusion. GRADE approach was used to assess certainty of evidence for the pre-specified outcomes. RESULTS: Fifteen trials (821 women) compared corticosteroids with placebo or no treatment. The effect of corticosteroids is uncertain for the primary outcome i.e., maternal death (risk ratio [RR] 0.77, 95% confidence interval [CI] 0.25 to 2.38, very low certainty evidence). Out of 6 studies reporting maternal death, 5 were judged overall to have "low risk" of bias. The effect of corticosteroids is also uncertain for other important outcomes including pulmonary edema (RR 0.70, 95% CI 0.23 to 2.09), dialysis (RR 3, 95% CI 0.13 to 70.78), liver morbidity (hematoma, rupture, and failure; RR 0.22, 95% CI 0.03 to 1.83), or perinatal death (0.64, 95% CI 0.21 to 1.97) because of very low certainty evidence. Low certainty evidence suggests that corticosteroids have little or no effect on the need for platelet transfusion (RR 0.98, 95% CI 0.60 to 1.60) and may result in a slight reduction in acute renal failure (RR 0.67, 95% CI 0.40 to 1.12). Subgroup and sensitivity analyses showed results that were similar to the primary synthesis. CONCLUSIONS: In women with HELLP syndrome, the effect of corticosteroids vs. placebo or no treatment is uncertain for patient-relevant outcomes including maternal death, maternal morbidity, and perinatal death. These uncertainties regarding this critical question should be addressed by adequately powered rigorous trials. SYSTEMATIC REVIEW REGISTRATION: Center for Open Science, osf.io/yzku5.

Transumbilical Vaginoplasty Through Fractionated Miniports: A Sutureless Procedure.

BACKGROUND: Vaginal agenesis is a müllerian anomaly characterized by congenital absence of the vagina. In this case series, the authors describe a novel, minimally invasive technique using microport entry for treatment of complete vaginal agenesis. TECHNIQUE: A balloon catheter is passed through a fenestrated perfluoroalkoxy polymer resin-supporting platform, then tied by a silk suture over the caudal end of the inserter. Two 4-mm microports are created intraumbilically; one to insert the scope and the other to introduce the catheter inserter that is advanced under direct vision. The inserter loaded with a catheter is passed across the pelvic floor to position the balloon at the vaginal dimple. The balloon is inflated and tightly positioned against the dimple. The perfluoroalkoxy polymer resin piece is clamped at the umbilicus. Traction is applied to the catheter stem and increased progressively to achieve desired vaginal depth. EXPERIENCE: Twenty-two women aged 17-28 years with vaginal agenesis underwent microport vaginoplasty. Twenty-one women were diagnosed with müllerian agenesis and one patient with androgen insensitivity syndrome. Preoperative vaginal depth ranged between 0.5 and 3 cm. The procedure was well tolerated with no intraoperative or postoperative complications. Patients achieved neovaginal depth between 9 and 11 cm and penetrations scores increased to 80-90%. CONCLUSION: Microport vaginoplasty is a feasible and effective procedure for management of vaginal agenesis.

Dimensional evaluation of blood clot gap distances within intrabony defects following grafting and EDTA root surface treatment-experimental study in dogs.

BACKGROUND: Because it is important to establish and maintain a firm blood clot to the surrounding tissues within the intrabony lesion; we have to investigate the potentials of different materials in resisting clot retraction that disrupt clot adhesion to the root surface. This study was designed to measure the gap distance created by clot retraction within the defect following intrabony defects grafting with and without root surface EDTA etching. METHODS: Eight mongrel dogs with surgically created acute-chronic bilateral mandibular interproximal intrabony defects in the premolar-molar areas were enrolled in this study (total 8 defects per dog). Intrabony defects were divided into four groups, the first group (OFD): control open flap debridement, the second group, (EDTA treated defects) in which debridement of the defects was followed by two minute root surface etching with a neutral 24% EDTA gel followed by two minute copious saline irrigation, the third group (only grafted defects): defects received closely packed ß-TCP of a particle size ranged from 150 to 500 mm, and the fourth group, (Graft + EDTA treated defects): defects were etched for 2 minutes with a neutral 24% EDTA gel and saline irrigation followed by intrabony defect fill of ß-TCP. Twenty four hours post treatment, animal euthanasia was carried out for histomorphometric analysis of the tooth and root side gap distances. RESULTS: EDTA treated group and EDTA + graft group showed statistically significant lower degree of clot shrinkage compared to both the control and only grafted group. Clot shrinkage in EDTA treated group showed no significant difference from that of the EDTA + graft group (p = 0.197). OFD and only grafted groups were found to show statistically higher clot retraction percnetage compared to both EDTA and EDTA+graft groups. CONCLUSION: following intrabony defect debridement, blood clot undergoes clot retraction creating a micro gap with the root surface. EDTA root surface etching before graft application into the defect area significantly reduced the amount of gap distance.