Hormone therapy effect on menopausal systemic lupus erythematosus patients: a systematic review.

Systemic lupus erythematosus (SLE) primarily affects women, who may need hormone therapy (HT) in menopause. There is, however, some concern as to its efficacy and safety. This systematic review aimed to determine the effect of HT on the activity of SLE and its safety. The study was a qualitative systematic review. Research was conducted with data retrieved from Embase, MEDLINE and Cochrane databases using MESH terms up to April 2021, with no bar on date or language. Sixteen studies were selected for analysis. Most of them showed HT to be effective in the treatment of menopausal symptoms with no impact in SLE activity, but one randomized clinical trial showed an increase in the number of thrombotic events. The present systematic review demonstrated the efficacy of HT for treating the menopausal symptoms of SLE patients. The risk of flare and thrombosis seems to be very low.

Incidence and outcome of prenatal brain abnormality in twin-to-twin transfusion syndrome: systematic review and meta-analysis.

OBJECTIVES: To evaluate the incidence of antenatally diagnosed brain injury in twin pregnancy complicated by twin-to-twin transfusion syndrome (TTTS) and to quantify the perinatal mortality, morbidity and long-term neurodevelopmental outcome of these fetuses. METHODS: MEDLINE, EMBASE, ClinicalTrials.gov and The Cochrane Library databases were searched. Inclusion criteria were studies reporting on brain abnormality diagnosed antenatally in twin pregnancies complicated by TTTS. The primary outcome was the incidence of prenatal brain abnormality. The secondary outcomes were intrauterine demise (IUD), neonatal death, termination of pregnancy (TOP) and long-term morbidity. Outcomes were explored in the population of fetuses with antenatal diagnosis of brain abnormality. Subgroup analysis according to the type of treatment, gestational age, Quintero stage at diagnosis and/or treatment, and cotwin death was planned. Meta-analysis of proportions was used to combine data and pooled proportions and their 95% CI were reported. RESULTS: Thirteen studies including 1573 cases of TTTS and 88 fetuses with an antenatal diagnosis of brain abnormality were included in the systematic review. The meta-analysis included only studies reporting on brain abnormality in twin pregnancy complicated by TTTS cases and treated with laser surgery. Overall, brain injury occurred in 2.2% (52/2410) of fetuses (eight studies). Brain abnormality was reported in 1.03% and 0.82% of recipients and donors, respectively. The most common type of abnormality was ischemic lesions (30.4% (95% CI, 19.1-43.0%)), followed by destructive lesions (23.9% (95% CI, 13.7-35.9%)), ventriculomegaly (19.9% (95% CI, 10.6-31.3%)) and hemorrhagic lesions (15.3% (95% CI, 7.1-25.8%)). Spontaneous IUD occurred in 13.4% (95% CI, 5.1-24.8%) of fetuses, while TOP was chosen by parents in 53.5% (95% CI, 38.9-67.8%) cases. Neonatal death was reported by only three studies, with an incidence of 15.4% (95% CI, 2.8-35.4%). Finally, only two studies reported on composite morbidity, with an overall rate of the outcome of 20.4% (95% CI, 2.5-49.4%) and rates of 29.7% and 20.4% in the recipient and donor fetuses, respectively. Due to the small numbers, only composite morbidity was analyzed and no information on neonatal intensive care unit admission, respiratory distress syndrome or other long-term outcomes, such as neurodevelopmental delay and cerebral palsy, could be retrieved reliably. CONCLUSIONS: The overall incidence of antenatally diagnosed fetal brain abnormality in twin pregnancy complicated by TTTS treated with laser surgery is around 2% and is mainly ischemic in nature (30.4%). TOP was chosen by parents in more than half of cases (53.5%). No information could be retrieved on morbidity outcomes, highlighting the urgent need for long-term follow-up studies of these children. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Effect of monochorionicity on perinatal outcome and growth discordance in triplet pregnancy: collaborative multicenter study in England, 2000-2013.

OBJECTIVES: To compare perinatal outcome and growth discordance between trichorionic triamniotic (TCTA) and dichorionic triamniotic (DCTA) or monochorionic triamniotic (MCTA) triplet pregnancies. METHODS: This was a multicenter cohort study using population-based data on triplet pregnancies from 11 Northern Survey of Twin and Multiple Pregnancy (NorSTAMP) maternity units and the Southwest Thames Region of London Obstetric Research Collaborative (STORK) multiple pregnancy cohort, for 2000-2013. Perinatal outcomes (from ≥ 24 weeks' gestation to 28 days of age), intertriplet fetal growth and birth-weight (BW) discordance and neonatal morbidity were analyzed in TCTA compared with DCTA/MCTA pregnancies. RESULTS: Monochorionic placentation of a pair or trio in triplet pregnancy (n = 72) was associated with a significantly increased risk of perinatal mortality (risk ratio, 2.7 (95% CI, 1.3-5.5)) compared with that in TCTA pregnancies (n = 68), due mainly to a much higher risk of stillbirth (risk ratio, 5.4 (95% CI, 1.6-18.2)), with 57% of all stillbirth cases resulting from fetofetal transfusion syndrome, while there was no significant difference in neonatal mortality (P = 0.60). The associations with perinatal mortality and stillbirth persisted when considering only pregnancies not affected by a major congenital anomaly. DCTA/MCTA triplets had lower BW and demonstrated greater BW discordance than did TCTA triplets (P = 0.049). Severe BW discordance of > 35% was 2.5-fold higher in DCTA/MCTA compared with TCTA pregnancies (26.1% vs 10.4%), but this difference did not reach statistical significance (P = 0.06), presumably due to low numbers. Triplets in both groups were delivered by Cesarean section in over 95% of cases, at a similar gestational age (median, 33 weeks' gestation). The rate of respiratory (P = 0.28) or infectious (P = 0.08) neonatal morbidity was similar between the groups. CONCLUSIONS: Despite close antenatal surveillance, monochorionic placentation of a pair or trio in triamniotic triplet pregnancy was associated with a significantly increased stillbirth risk, mainly due to fetofetal transfusion syndrome, and with greater size discordance. In liveborn triplets, there was no adverse effect of monochorionicity on neonatal outcome. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Early- and late-onset selective fetal growth restriction in monochorionic diamniotic twin pregnancy: natural history and diagnostic criteria.

OBJECTIVES: To evaluate the natural history and outcome of selective fetal growth restriction (sFGR) in monochorionic diamniotic (MCDA) twin pregnancy, according to gestational age at onset and various reported diagnostic criteria, and to quantify the risk of superimposed twin-to-twin transfusion syndrome (TTTS). METHODS: This was a cohort study of MCDA twin pregnancies that had their routine antenatal care from the first trimester at St George's Hospital, London, UK. Pregnancies had ultrasound examinations every 2 weeks at 16-24 weeks and then every 2-3 weeks until delivery. The diagnostic criteria for sFGR were estimated fetal weight (EFW) of one twin < 10th centile and intertwin EFW discordance ≥ 25%. We also applied other diagnostic criteria reported in a recent Delphi consensus. Pregnancies in which the diagnosis of TTTS was made before that of sFGR were not included in the analysis. Pregnancies that underwent fetal intervention for sFGR were excluded. The incidence of sFGR was compared between the different diagnostic criteria, overall and according to gestational age at onset. In all subsequent analyses, cases of sFGR included those diagnosed according to any of the criteria. The Gratacós classification of sFGR was applied (Type I, II or III). Pregnancy outcomes included miscarriage, intrauterine death, neonatal death and admission to the neonatal unit. Comparisons between groups were carried out using the Mann-Whitney U-test for continuous variables and the chi-square or Fisher's exact test for categorical variables. RESULTS: The analysis included 287 MCDA twin pregnancies. According to the International Society of Ultrasound in Obstetrics and Gynecology diagnostic criteria, the incidence of early (< 24 weeks) sFGR was 4.9%, while that of late sFGR was 3.8%. When applying the various diagnostic criteria, the incidence of early sFGR varied from 1.7% to 9.1% and that of late sFGR varied from 1.1% to 5.9%. In early-onset cases, the incidence of Type I sFGR was 80.8%, that of Type II was 15.4% and that of Type III was 3.8%. The corresponding figures in late-onset cases were 94.4%, 5.6% and 0%. The incidence of superimposed TTTS was 26.9% in cases affected by early-onset sFGR and 5.6% in those affected by late-onset sFGR. The incidence of perinatal death was 8.0% in early-onset sFGR and 5.6% in late-onset sFGR (P = 0.661). Admission to the neonatal unit occurred in 61.0% and 52.9% of cases, respectively (P = 0.484). CONCLUSIONS: In MCDA twin pregnancies, early-onset sFGR is slightly more common than is late-onset sFGR, although this difference was not significant, and is associated with worse perinatal outcome. The incidence of Types II and III sFGR is higher in early-onset sFGR. The incidence also varies according to the diagnostic criteria used, which supports the use of standardized international diagnostic criteria. Superimposed TTTS is more common in early- than in late-onset sFGR. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Long-term neuroimaging and neurological outcome of fetal spina bifida aperta after postnatal surgical repair.

OBJECTIVE: Parents faced with the choice between postnatal management and prenatal surgery for spina bifida need to have up-to-date information on the expected outcomes. The aim of this study was to report the long-term physical and neurological outcomes of infants with prenatally diagnosed isolated spina bifida that underwent postnatal surgical repair and were managed by a multidisciplinary team from a large tertiary center. METHODS: This was a retrospective cohort study of all cases of fetal spina bifida managed in a tertiary unit between October 1999 and January 2018. All cases of fetal spina bifida from the local health region were routinely referred to the tertiary unit for further perinatal management. Details on surgical procedures and neonatal neurological outcomes were obtained from institutional case records. Ambulatory status, bladder and bowel continence and neurodevelopment were assessed at a minimum of 3 years. RESULTS: During the study period, 241 pregnancies with isolated spina bifida were seen in the unit. Of these, 84 (34.9%) women opted to continue with the pregnancy after multidisciplinary counseling by clinicians. Sixty-seven infants underwent postnatal repair of spina bifida aperta and were included in the analysis. After birth, hindbrain herniation was observed in 91.5% of infants with only seven requiring surgical decompression. Ventriculoperitoneal shunt placement was needed in 64.2% of infants, while normal cognitive development or mild impairment was demonstrated in 85.4% of cases with data for this outcome available, at a mean age of 8 years. Cumulatively, 40% of infants were walking independently or using minor support, and normal or mild impairment of bladder and bowel function was reported in 45.5% and 44.4% of infants, respectively. CONCLUSIONS: Neurodevelopmental and neurological outcomes between prenatal and postnatal repair are similar. As with fetal surgery, conventional postnatal surgery is associated with the reversal of hindbrain herniation. Similarly, postnatal ventriculoperitoneal shunt placement appears to be required mainly in fetuses without evidence of significant fetal ventriculomegaly. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Perinatal mortality and morbidity in triplet pregnancy according to chorionicity: systematic review and meta-analysis.

OBJECTIVE: The incidence of perinatal mortality and morbidity in triplet pregnancies according to chorionicity is yet to be established. The aim of this systematic review was to quantify perinatal mortality and morbidity in trichorionic triamniotic (TCTA), dichorionic triamniotic (DCTA) and monochorionic triamniotic (MCTA) triplets. METHODS: MEDLINE, EMBASE and CINAHL databases were searched in December 2017 for literature published in English describing outcomes of DCTA, TCTA and/or MCTA triplet pregnancies. Primary outcomes were intrauterine death (IUD), neonatal death, perinatal death (PND) and gestational age at birth. Secondary outcomes comprised respiratory, neurological and infectious morbidity, as well as a composite score of neonatal morbidity. Data regarding outcomes were extracted from the included studies. Random-effects meta-analysis was used to estimate the risk of mortality and morbidity and to compute the difference in gestational age at birth between TCTA and DCTA triplet pregnancies. RESULTS: Nine studies (1373 triplet pregnancies, of which 1062 were TCTA, 261 DCTA and 50 MCTA) were included in the analysis. The risk of PND was higher in DCTA than in TCTA triplet pregnancies (odds ratio (OR), 3.3 (95% CI, 1.3-8.0)), mainly owing to the higher risk of IUD in DCTA triplet pregnancies (OR, 4.6 (95% CI, 1.8-11.7)). There was no difference in gestational age at birth between TCTA and DCTA triplets (mean difference, 1.1 weeks (95% CI, -0.3 to 2.5 weeks); I2 = 85%; P = 0.12). Neurological morbidity occurred in 2.0% (95% CI, 1.1-3.3%) of TCTA and in 11.6% (95% CI, 1.1-40.0%) of DCTA triplets. Respiratory and infectious morbidity affected 28.3% (95% CI, 20.7-36.8%) and 4.2% (95% CI, 2.8-5.9%) of TCTA and 34.0% (95% CI, 21.5-47.7%) and 7.1% (95% CI, 2.7-13.3%) of DCTA triplets, respectively. The incidence of composite morbidity in TCTA and DCTA triplets was 29.6% (95% CI, 21.1-38.9%) and 34.0% (95% CI, 21.5-47.7%), respectively. When translating these figures into a risk analysis, the risk of neurological morbidity (OR, 5.4 (95% CI, 1.6-18.3)) was significantly higher in DCTA than in TCTA triplets, while there was no significant difference in the other morbidities explored. Only one study reported on outcomes of MCTA pregnancies, hence, no formal comparison with the other groups was performed. CONCLUSION: DCTA triplets are at higher risk of perinatal mortality and morbidity than are TCTA triplets. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Analysis of risk factors of the postoperative complications of surgical treatment of ankle fractures in the elderly: A series of 477 patients.

INTRODUCTION: The surgical strategy of ankle fractures in elderly subjects is controversial because of the high rate of local and general complications. The goal of this study was to identify the risk factors of complications of ankle fractures in elderly subjects. MATERIALS AND METHODS: Four hundred and seventy-seven patients operated between 2008 and 2014 were included in this retrospective study. The minimum age was 60 years old for women and 70 for men. Patients presenting with a pilon fracture or with less than 3 months of follow up were excluded. A clinical evaluation of autonomy based on the Parker score and a radiographic assessment were performed preoperatively and during follow up The characteristics of the fracture, comorbidities and the type of internal fixation used were reported. RESULTS: This series included 384 women (81%), mean age 74 years old (60-99). Most fractures were Weber type B (n=336). Four hundred and thirty-one patients (90.4%) received so-called standard internal fixation and 46 patients (9.6%) received so-called atypical fixation. The rate of general complications was 4.6%, and local complications was 23.9%. Univariate analysis of the risk factors of general complications identified 2 significant criteria: age older than 80 (OR=3.46, P=0.012) and more than 2 comorbidities 2 (OR=10.6, P<0.0001). Univariate analysis of risk factors of local complications identified 2 criteria: an open fracture (OR=4.90, P=0.0016) and age over 80 (OR=1.85, P=0.024). Multivariate analysis of risk factors of local complications confirmed the relationship with open fractures (OR=4.67, P<0.001). DISCUSSION: The results of the management of ankle fractures in elderly subjects is satisfactory. The use of standard internal fixation techniques is recommended. The risk of complications increases with age, the severity of the fracture and the number of associated diseases. LEVEL OF EVIDENCE: Level 4.

Refinements in transverse rectus abdominis myocutaneous flap breast reconstruction: projection and contour improvements.

A surgical procedure with the transverse rectus abdominis myocutaneous (TRAM) flap for breast reconstruction is presented using parameters from the opposite normal breast to achieve a better cone shape in the new breast to project the nipple-areola complex. This cone projection is obtained through a vertical plication of both skin/fat halves of the TRAM flap and with two supraumbilical fat flaps to avoid cone collapse. The infraclavicular and axillary regions are filled with a de-epithelialized "fish-fin" cutaneous-fat or fat-only flap, which is placed as a lateral TRAM extension. The de-epithelialized lateral extremity of the TRAM flap folded over itself gives a mound shape to the lateral aspect of the new breast, and the inverted umbilical stalk attached to the TRAM flap imitates a nipple. This procedure is based on six breast reconstructions with a 2-year follow-up. The procedure is a simple, safe, and versatile way to mimic the opposite breast. It is mostly indicated for thin patients who have small to moderate breasts without ptosis or hypertrophy who refuse breast implants or request a mastopexy or reduction mammaplasty on the opposite normal breast during the same procedure.

[Urologic complications of pancreas-kidney simultaneous transplantation]. / Complicaciones urológicas en el trasplante simultáneo de pancreas-riñón.

Pancreas Transplantation (PT) is the only available therapy today for diabetes that allows an insulin-independent euglycemic state with complete normalization of glycosilated haemoglobin levels. Survival of patient, pancreatic graft and renal graft is 93%, 86% and 90% respectively at one year and 90%, 84% and 85% at three years. The most accepted method for exocrine drainage in most centres where simultaneous pancreas-kidney transplantation is being performed is vesical drainage. In spite of the improvements achieved in graft and patient survival, it is evident that a most frequent use of this type of technique involves a greater number of urological complications (repeat infections, haematuria, fistulae or leakage, reflux pancreatitis, urethral stenosis and disruption, dehydration and acidosis, previous diabetic bladder) and the familiarization of the urologist with this type of disease in immunodepressed patients. This paper reviews the current situation and illustrates the general approach regimes in our Pancreas-Kidney Transplantation Unit with regard to each complication.