Unlocking the Hidden Pathway: A Rare Encounter With Right Coronary Artery Fistula to Coronary Sinus and Right Ventricle.

Coronary artery fistulas (CAFs) are rare vascular anomalies characterized by abnormal connections between coronary arteries and cardiac chambers or adjacent structures. Advances in cardiac interventions have led to an increasing recognition of acquired CAFs, which are typically congenital. We present a case of a 62-year-old male with a complex medical history, including hypertension, atrial fibrillation, and heart failure, who presented with exertional chest pain and palpitations. Diagnostic evaluation revealed a significant CAF originating from the right coronary artery (RCA) and terminating into the coronary sinus and right ventricle. Despite the absence of significant coronary artery occlusions, the fistula was deemed clinically significant due to its potential to cause myocardial ischemia. Management involved guideline-directed medical therapy and lifestyle modifications. This case underscores the importance of early recognition and appropriate management of CAFs to optimize patient outcomes. Further research is needed to better understand the natural history and optimal management strategies of CAFs.

SIRT1 regulates hepatic vldlr levels.

BACKGROUND: Endoplasmic reticulum (ER) stress-mediated increases in the hepatic levels of the very low-density lipoprotein (VLDL) receptor (VLDLR) promote hepatic steatosis by increasing the delivery of triglyceride-rich lipoproteins to the liver. Here, we examined whether the NAD(+)-dependent deacetylase sirtuin 1 (SIRT1) regulates hepatic lipid accumulation by modulating VLDLR levels and the subsequent uptake of triglyceride-rich lipoproteins. METHODS: Rats fed with fructose in drinking water, Sirt1-/- mice, mice treated with the ER stressor tunicamycin with or without a SIRT1 activator, and human Huh-7 hepatoma cells transfected with siRNA or exposed to tunicamycin or different inhibitors were used. RESULTS: Hepatic SIRT1 protein levels were reduced, while those of VLDLR were upregulated in the rat model of metabolic dysfunction-associated steatotic liver disease (MASLD) induced by fructose-drinking water. Moreover, Sirt1-/- mice displayed increased hepatic VLDLR levels that were not associated with ER stress, but were accompanied by an increased expression of hypoxia-inducible factor 1α (HIF-1α)-target genes. The pharmacological inhibition or gene knockdown of SIRT1 upregulated VLDLR protein levels in the human Huh-7 hepatoma cell line, with this increase abolished by the pharmacological inhibition of HIF-1α. Finally, SIRT1 activation prevented the increase in hepatic VLDLR protein levels in mice treated with the ER stressor tunicamycin. CONCLUSIONS: Overall, these findings suggest that SIRT1 attenuates fatty liver development by modulating hepatic VLDLR levels.

Maternal, Perinatal and Neonatal Outcomes of Triplet Pregnancies According to Chorionicity: Our 15-Year Experience in a Tertiary-Level Center.

Introduction: The goal of this study was to evaluate the effect of chorionicity on maternal, fetal and neonatal morbidity and mortality in triplet pregnancies in our environment. Methods: A retrospective observational study was carried out on triplet pregnancies that were delivered in a tertiary center between 2006 and 2020. A total of 76 pregnant women, 228 fetuses and 226 live newborns were analyzed. Of these triplet pregnancies, half were non-trichorionic. We analyzed maternal characteristics and obstetric, fetal, perinatal and neonatal complications based on their chorionicity, comparing trichorionic vs. non-trichorionic triplet pregnancies. Prematurity was defined as <34 weeks. We measured perinatal and neonatal mortality, composite neonatal morbidity and composite maternal morbidity. Results: Newborns with a monochorionic component had a lower gestational age at birth, presented greater prematurity under 34 weeks, lower birth weight, greater probability of birth weight under 2000 g and an APGAR score below 7 at 5 min after birth, more respiratory distress syndrome and, overall, higher composite neonatal morbidity. The monochorionic component of triple pregnancies may entail the development of complications intrinsic to shared circulation and require premature elective termination. This greater prematurity is also associated with a lower birth weight and to the main neonatal complications observed. These findings are in line with those that were previously published in the meta-analysis by our research group and previous literature. Discussion: Triplet gestations with a monochorionic component present a higher risk of obstetric, fetal and neonatal morbidity and mortality.

Post-COVID-19 condition in pregnant and postpartum women: a long-term follow-up, observational prospective study.

Background: Post-COVID-19 condition has recently been defined as new or persistent common COVID-19 symptoms occurring three months after disease onset. The pathology of the disease is unclear, but immune and vascular factors seem to play a significant role. The incidence, severity, and implications of the disease after COVID-19 infection in pregnancy have not been established. We aimed to study the incidence and main risk factors for post-COVID-19 condition in an obstetric population and their implications for maternal and perinatal morbimortality. Methods: This is a prospective observational cohort study undertaken including women during pregnancy or at admission for labour with acute COVID-19 infection from March 9th, 2020 to June 11th, 2022. The inclusion criteria were confirmed acute COVID-19 infection during the recruitment period, a lack of significant language barrier and consent for follow-up. Patients were clinically followed-up by telephone via semi structured questionnaires. The exclusion criteria were loss to follow-up, spontaneous miscarriage, and legal termination of pregnancy. Patients were classified into groups according to the severity of symptoms at onset. We included patients from the first six first waves of the pandemic according to national epidemiological data in Spain. We studied the incidence of post-COVID-19 condition and their main demographic, clinical and obstetric risk factors. Findings: A total of 409 pregnant women were recruited at acute diagnosis, and 286 were followed-up. The mean time to follow-up was 92 weeks (standard deviation ± 28 weeks; median 100 weeks (Interquartile range: 76; 112)). A total of 140 patients had at least one post-COVID-19 symptom at least three months after acute infection. Neurological (60%) and cutaneous (55%) manifestations were the most frequent findings. The following profiles were identified as presenting a higher risk of post-COVID-19 condition: migrant women born in countries with lower Human Development Index; multiparous women; women with COVID-19 during pregnancy, mainly during the first and third trimesters, and in the first and second waves of the pandemic; women who had a higher number of symptoms; women who had a higher incidence of moderate and severe symptoms; women who required hospitalisation due to COVID-19 complications; and women who were not vaccinated before disease onset. We did not find any significant difference in perinatal results, such as gestational week at delivery, birthweight, the need for neonatal care or 5-min Apgar score, and newborns benefited from a high rate of breastfeeding at discharge. Women who were infected during successive waves of the pandemic had a significant and constant decrease in the risk of post-COVID-19 condition comparing to estimated risk in the first wave (OR: 0.70; 95% CI: 0.62, 0.92). Symptoms tended to resolve over time heterogeneously. Symptoms of myalgia and arthralgia took longer to resolve (mean of 60 weeks and 54 weeks, respectively). In a small but significant proportion of patients, neurological and psycho-emotional symptoms tended to become chronic after 90 weeks. Interpretation: At least 34.2% of obstetric patients from our cohort with acute COVID-19 infection presented post-COVID-19 condition symptoms. Demographic and acute disease characteristics as well as specific pregnancy-related risk factors were identified. This is the first study to assess post-COVID-19 condition in pregnant women. Further analysis on the biological pathophysiology of post-COVID-19 is needed to explain the characteristics of the disease. Funding: This study has been funded by Instituto de Salud Carlos III (ISCIII) through the project "PI21/01244" and co-funded by the European Union, as well as P2022/BMD-7321 (Comunidad de Madrid) and ProACapital, Halekulani S.L. and MJR.

Elafibranor upregulates the EMT-inducer S100A4 via PPARß/δ.

Elafibranor is a dual peroxisome proliferator-activated receptor (PPAR)α and ß/δ agonist that has reached a phase III clinical trial for the treatment of metabolic dysfunction-associated steatotic liver disease (MASLD). Here, we examined the effects of elafibranor in mice fed a choline-deficient high-fat diet (CD-HFD), a model of metabolic dysfunction-associated steatohepatitis (MASH) that presents obesity and insulin resistance. Our findings revealed that elafibranor treatment ameliorated steatosis, inflammation, and fibrogenesis in the livers of CD-HFD-fed mice. Unexpectedly, elafibranor also increased the levels of the epithelial-mesenchymal transition (EMT)-promoting protein S100A4 via PPARß/δ activation. The increase in S100A4 protein levels caused by elafibranor was accompanied by changes in the levels of markers associated with the EMT program. The S100A4 induction caused by elafibranor was confirmed in the BRL-3A rat liver cells and a mouse primary hepatocyte culture. Furthermore, elafibranor reduced the levels of ASB2, a protein that promotes S100A4 degradation, while ASB2 overexpression prevented the stimulating effect of elafibranor on S100A4. Collectively, these findings reveal an unexpected hepatic effect of elafibranor on increasing S100A4 and promoting the EMT program.

Red Blood Cell Transfusion after Postpartum Hemorrhage: Clinical Variables Associated with Lack of Postpartum Hemorrhage Etiology Identification.

Postpartum hemorrhage (PPH) remains a significant obstetric emergency worldwide and a leading cause of maternal death. However, it is commonly underreported, which can represent a major concern for maternal morbidity and mortality. This retrospective case series study analyzed patients with red blood cell transfusion (RBCt) in the postpartum period over a four-year interval at a specific center. A total of 18,674 patients delivered between January 2018 and December 2021. Patients with postpartum RBCt were classified into two groups: those with identified PPH (i-PPH) and those without (non-i-PPH). Clinical variables, delivery details, blood loss data, and treatment information were collected. Statistical analysis involved a comparison of variables between the i-PPH and non-i-PPH groups. Univariate and multivariate analyses were performed, aiming to identify significant associations between the clinical variables and a lack of PPH identification. The incidence of RBCt was 1.26% (236 cases). Patients receiving RBCt had higher rates of cesarean delivery, twin pregnancy, labor induction, and previous cesarean section. Among patients with postpartum RBCt, 34.3% lacked an identified PPH. The rarity of postpartum RBCt contrasts with the increasing rates of PPH, highlighting the importance of diagnosing PPH and postpartum anemia. A strategy of systematic quantification of blood loss during delivery could help detect PPH and anemia before adverse consequences occur.

Workshop for Basic Gynaecological Examinations: Improving Medical Student Learning through Clinical Simulation.

INTRODUCTION: This study was designed to evaluate whether the Workshop on Basic Principles for Clinical Gynaecological Exploration, offered to medical students, improves theoretical-practical knowledge, safety, confidence, global satisfaction and the achievement of the proposed objectives in the area of gynaecological clinical examinations. MATERIALS AND METHODS: This was a quasi-experimental pre-post-learning study carried out at the Gynaecology and Obstetrics department of Gregorio Marañón Hospital in Madrid (Spain). The volunteer participants were 4th-year students earning a degree in Medicine during the 2020-2021 and 2021-2022 academic years. The study period was divided into the following stages: pre-workshop, intra-workshop and 2 weeks post-workshop. In the pre-workshop stage, students completed a brief online course to prepare for the workshop. The effectiveness of the workshop was evaluated through multiple-choice tests and self-administered questionnaires to assess self-assurance, self-confidence, self-satisfaction and the achievement of the objectives. RESULTS: Of the 277 students invited in both academic years, 256 attended the workshop (92.4%), with a total participation in the different stages of the study greater than 70%. A total of 82.5% of the students in the 2020-2021 academic year and 80.6% of students in the 2021-2022 academic year did not have any type of experience performing gynaecological clinical examinations. Between the pre-workshop and 2 weeks post-workshop stages, there was significant improvement in theoretical-practical knowledge (improvement mean = 1.38 and 1.21 in 2020-2021 and 2021-2022 academic years, respectively). The security and confidence of the students prior to the workshop were low (average scores less than 5 points) in both academic years. However, post-workshop scores for satisfaction and the achievement of objectives were high in the two academic years; all the values approached or exceeded 8 points. CONCLUSIONS: Our students, after outstanding participation, evaluated the BPCGE, and improved their theoretical and practical knowledge, as well as their skills in a gynaecological clinical examination. Moreover, in their view, after the workshop, they felt very satisfied, far outreaching the proposed aims. In addition, excellent results were maintained over time, year after year.

Serologic evolution and follow-up to IgG antibodies of infants born to mothers with gestational COVID.

BACKGROUND: It is known that SARS-CoV-2 antibodies from pregnant women with SARS-CoV-2 infection during pregnancy cross the placenta but the duration and the protective effect of these antibodies in infants is scarce. METHODS: This prospective study included mothers with SARS-COV-2 infection during pregnancy and their infants from April 2020 to March 2021. IgG antibodies to SARS-CoV-2 spike protein were performed on women and infants at birth and at two and six months during follow-up. Anthropometrical measures and physical and neurological examinations and a clinical history of symptoms and COVID-19 diagnosis were collected. Simple linear regression was performed to compare categorical and continuous variables. To compare the mother's and infant's antibody titers evolution, a mixed linear regression model was used. A predictive model of newborn antibody titers at birth has been established by means of simple stepwise linear regression. RESULTS: 51 mother-infant couples were included. 45 (90%) of the mothers and 44 (86.3%) of the newborns had a positive serology al birth. These antibodies were progressively decreasing and were positive in 34 (66.7%) and 7 (13.7%) of infants at 2 and 6 months, respectively. IgG titers of newborns at birth were related to mothers' titers, with a positive moderate correlation (Pearson's correlation coefficient: 0.82, p < 0,001). Fetal/maternal antibodies placental transference rate was 1.3 (IQR: 0.7-2.2). The maternal IgG titers at delivery and the type of maternal infection (acute, recent, or past infection) was significantly related with infants' antibody titers at birth. No other epidemiological or clinical factors were related to antibodies titers. Neurodevelopment, psychomotor development, and growth were normal in 94.2% of infants in the third follow-up visit. No infants had a COVID-19 diagnosis during the follow-up period. CONCLUSIONS: Transplacental transfer of maternal antibodies is high in newborns from mothers with recent or past infection at delivery, but these antibodies decrease after the first months of life. Infant's IgG titers were related to maternal IgG titers at delivery. Further studies are needed to learn about the protective role of maternal antibodies in infants.

Automated SSHHPS Analysis Predicts a Potential Host Protein Target Common to Several Neuroinvasive (+)ssRNA Viruses.

Within the viral genome, short stretches of homologous host pathogen sequences (SSHHPS) span the protease cleavage sites. To identify host proteins that may be cleaved during infection, we searched the human proteome for viral protease cleavage sites (~20 amino acids). We developed a sequence-to-symptom tool, automating the search and pairing process. We used the viral protein sequence, PHI-BLAST, and UniProt database for gene ontologies and disease relationships. We applied the tool to nine neuroinvasive viruses: Venezuelan and Eastern Equine encephalitis virus (VEEV, EEEV); severe acute respiratory syndrome (SARS, SARS-CoV-2); Middle East respiratory syndrome (MERS); EV-71; Japanese encephalitis virus (JEV); West Nile (WNV); and Zika (ZIKV). A comparison of the hits identified a protein common to all nine viruses called ADGRA2 (GPR124). ADGRA2 was a predicted hit of the 3CL main protease and papain-like protease (PLpro) of SARS-CoV-2. ADGRA2 is an adhesion G protein-coupled receptor and a key endothelial regulator of brain-specific angiogenesis. It is a Wnt7A/Wnt7B specific coactivator of beta-catenin signaling and is essential for blood-brain barrier (BBB) integrity in central nervous system (CNS) diseases. We show the cleavage of the predicted sequences in MYOM1, VWF by the SARS-CoV-2 PLpro; DNAH8 (dynein) by the MERS PLpro; ADGRA2 by the alphaviral VEEV nsP2 protease; and POT1 by the SARS-CoV-2 and MERS PLpro.

Phenomenological variables of autobiographical memory narrativesassociated with healthy habits in children / Variables fenomenológicas de narrativas de memoria autobiográfica asociadas a hábitos saludables en niños

Different studies relateself-defining memories (SDM) to psy-chological well-being and health. This study aims toanalyse the relation be-tween the phenomenological variables (e.g., emotional intensity, vividness etc.) involved in self-defining memories associated with health (HSDMs) and healthy habits in 262 children aged between 9 and 13 years. Partici-pants’ eating habits and physical activity events are associated with the emotionality of their HSDMs. Most of the HSDMs were declared to be experienced with their family members, and greater importance was at-tributed to those memories related to mothers. Significant features of re-trieved HSDM can be detected from construction of autobiographical memories supporting the development of a robust healthy self in children. As such, families and schools should facilitate life experiences that lead to the formation of vivid and detailed HSDMs given that this is likely to promote health-related behaviours.(AU)

Diferentes estudios relacionan los recuerdos autodefinidos (SDM) con el bienestar psicológico y la salud. Este estudio tiene como objetivo analizar la relación entre las variables fenomenológicas (p. ej., intensidad emocional, viveza, etc.) implicadas en los recuerdos autodefinidos asociados a la salud (HSDM) y los hábitos saludables en 262 niños de entre 9 y 13 años. Los hábitos alimentarios y los eventos de actividad física de los participantes están asociados con la emotividad de sus HSDM. La mayoría de los HSDM declararon ser vividos con sus familiares, y se atribuyó mayor importancia a aquellos recuerdos relacionados con las madres. Se pueden detectar características significativas del HSDM recuperado a partir de la construcción de recuerdos autobiográficos que respaldan el desarrollo de un yo saludable y robusto en los niños. Como tal, las familias y las escuelas deben facilitar experiencias de vida que conduzcan a la formación de HSDM vívidos y detallados, dado que es probable que esto promueva comportamientos relacionados con la salud.(AU)

Improvement of Low-Grade Inflammation in Patients with Metabolically Healthy Severe Obesity After Primary Bariatric Surgery.

INTRODUCTION: The inflammatory state that accompanies adiposity and the metabolic syndrome (MetS) is called "low-grade" inflammation. White blood cell count (WBC) has been proposed as an emerging biomarker for predicting future cardiovascular events, MetS and mortality. Bariatric surgery (BS) improves comorbidities associated with obesity and the MetS and the surgically induced weight loss is known to improve inflammatory status. OBJECTIVES: To analyze the improvement of low-grade inflammation associated to obesity in patients with metabolically healthy severe obesity (MHSO) and patients with metabolically unhealthy obesity (MUSO) (severe obesity with MetS) after primary bariatric surgery as well as the protective effect of BS against the development of MetS in patients with MHSO by reducing the WBC. MATERIALS AND METHODS: Retrospective analysis of prospectively collected data of patients undergoing laparoscopic primary BS (gastric by-pass or sleeve gastrectomy) from January 2004-December 2015. Outcomes included changing of low-grade inflammation in terms of leukocytes, neutrophils, lymphocytes, and platelets. RESULTS: Twenty-one patients with MHSO and 167 patients with MUSO underwent laparoscopic primary BS. The preoperative values of leukocyte and platelet were statistically higher in the group of patients with MHSO. In both groups, there was significant postoperative decrease of inflammatory markers. The greatest drop in WBC occurred in the second postoperative year. No patient of the group of patients with MHSO developed MetS within five postoperative years. CONCLUSIONS: Surgically induced weight loss plays an important role for improvement in chronic inflammation associated to obesity because of reduction of visceral fat mass. MHSO associates a low-grade chronic inflammatory status comparable to MUSO. The improvement or decrease of low-grade inflammation in patients with metabolically healthy severe obesity after bariatric surgery could have a protective effect against the development of MetS and medical conditions associated with severe obesity.

A positive feedback loop between AMPK and GDF15 promotes metformin antidiabetic effects.

BACKGROUND AND AIMS: Metformin, the most prescribed drug for the treatment of type 2 diabetes mellitus, has been recently reported to promote weight loss by upregulating the anorectic cytokine growth differentiation factor 15 (GDF15). Since the antidiabetic effects of metformin are mostly mediated by the activation of AMPK, a key metabolic sensor in energy homeostasis, we examined whether the activation of this kinase by metformin was dependent on GDF15. METHODS: Cultured hepatocytes and myotubes, and wild-type and Gdf15-/- mice were utilized in a series of studies to investigate the involvement of GDF15 in the activation of AMPK by metformin. RESULTS: A low dose of metformin increased GDF15 levels without significantly reducing body weight or food intake, but it ameliorated glucose intolerance and activated AMPK in the liver and skeletal muscle of wild-type mice but not Gdf15-/- mice fed a high-fat diet. Cultured hepatocytes and myotubes treated with metformin showed AMPK-mediated increases in GDF15 levels independently of its central receptor GFRAL, while Gdf15 knockdown blunted the effect of metformin on AMPK activation, suggesting that AMPK is required for the metformin-mediated increase in GDF15, which in turn is needed to sustain the full activation of this kinase independently of the CNS. CONCLUSION: Overall, these findings uncover a novel mechanism through which GDF15 upregulation by metformin is involved in achieving and sustaining full AMPK activation by this drug independently of the CNS.

Checklist: A Useful and Safe Tool for the Initiation of Care for Eutocical Vaginal Delivery.

The aim of this study is to present and analyze the vaginal delivery checklist as a safe and useful learning tool for first-year residents in the gynecology and obstetrics and midwifery specialties at different hospitals and to analyze the items that comprise it and the progress of the residents during the first 30 normal deliveries attended in a supervised manner. We present a descriptive, observational and prospective study in which 18 participants from different hospitals in Spain completed a checklist of skills in the first 30 births attended autonomously after learning its use in a simulation workshop. We collected a total of 329 of 330 checklists completed by 11 participants. In addition, the mean responses for each item contained on the checklist and the mean global progression of the participants were subsequently analyzed, detecting statistically significant differences using Student's t-test for paired data. During the data collection period between September 2020 and August 2021, a total of 329 checklists were analyzed. The global average of positive responses for the 30 questions contained on the checklist was 25.36 out of 30 points. The fulfillment of the different items was variable, with the lowest fulfillment of 2.18 points, although 73% of the items obtained a score greater than 25. A statistically significant difference in the mean compliance of the first five childbirths compared to the last five deliveries using the proposed checklist was obtained, with p < 0.01. In conclusion, knowing the importance of using a checklist to anticipate risk situations and reduce the number of adverse perinatal outcomes, we can say that, for first-year residents in gynecology and obstetrics attending a clinical simulation workshop in eutocic vaginal delivery, it may be interesting to have a tool, such as the checklist proposed in this study, that facilitates the learning process and the suitable progress of the participants.

3D Ultrasound in Pelvic Floor: Is It Useful as a Prognostic Tool in Type of Labor Development and Subsequent Pelvic Floor Diseases?

The objective of our study is to determine the thickness of the pubovisceral fasciculus of the levator ani muscle and the area of the genital hiatus by means of three-dimensional perineal ultrasound, in pregnant women in the 2nd trimester, and to analyze the related maternal, perinatal and postpartum clinical variables. Furthermore, to compare the results of our study with two similar series previously published. An observational, prospective study of pelvic floor ultrasound was carried out, performed at week 20, whose delivery was attended in the obstetrics service of the Hospital General Universitario Gregorio Marañón de Madrid (HGUGM), during the period of August from 2021 to June 2022. Maternal, ultrasound, perinatal and postpartum clinical variables were collected from each participant. During the study period, a total of 54 patients were included in it. The mean gestational age at which the ultrasound was performed was 19.81 ± 0.91 weeks. In relation to the ultrasound variables, the mean thickness of the pubovisceral muscle was 0.87 ± 0.13 cm (95% CI, 0.64-1.38 cm), while, in the plane of minimum dimension of the genital hiatus, the hiatal area at rest was 13.41 ± 3.22 (95% CI, 4.60-18.78) cm2. There is a significant correlation between the age of pregnant women (over 35 years of age) and the increase in the area of the genital hiatus (r = 0.295, p = 0.031). 3D ultrasound of the pelvic floor performed at week 20 of gestation can to be an effective, non-invasive, reproducible and cheap tool in the prognosis of the development of labor and of possible subsequent perineal dysfunctions.

Knocking on GDF15's door for the treatment of type 2 diabetes mellitus.

Although a large number of drugs are available for the treatment of type 2 diabetes mellitus (T2DM), many patients do not achieve adequate disease control despite adhering to medication. Recent findings indicate that the pharmacological modulation of the stress-induced cytokine growth differentiation factor 15 (GDF15) shows promise for the treatment of T2DM. GDF15 suppresses appetite and reduces inflammation, increases thermogenesis and lipid catabolism, sustains AMP-activated protein kinase (AMPK) activity, and ameliorates insulin resistance and hepatic steatosis. In addition, circulating GDF15 levels are elevated in response to several antidiabetic drugs, including metformin, with GDF15 mediating some of their effects. Here, we review the mechanistic insights into the beneficial effects of recently explored therapeutic approaches that target GDF15 for the treatment of T2DM.

Uterine Artery Embolization of Uterine Arteriovenous Malformation: A Systematic Review of Success Rate, Complications, and Posterior Pregnancy Outcomes.

Uterine Arteriovenous Malformation (UAVM) is a rare but life-threating cause of uterine bleeding. The clinical management of this condition is challenging, and there is a need to describe the most adequate approach for these patients. Uterine artery embolization (UAE) is the most widely-published treatment in the literature in recent years, although there is a need to update the evidence on this treatment and to compare it with other available therapies. Thus, the objective of this systematic review is to quantify the efficacy of UAE of UAVM. In addition, we evaluated the clinical context of the patients included, the treatment complications, and the pregnancy outcomes after UAE. With this goal in mind, we finally included 371 patients spread over all continents who were included in 95 studies. Our results show that, similar to other medical therapies, the global success rate after embolization treatment was 88.4%, presenting a low risk of adverse outcomes (1.8%), even in women with later pregnancy (77% had no complications). To date, this is the largest systematic review conducted in this field, although there are still some points to address in future studies. The results obtained in our study should be outlined in UAE protocols and guidelines to aid in clinical decision-making in patients with UAVM.

Pain control with punch grafting in ulcers with underlying arteriolosclerosis.

OBJECTIVE: Martorell hypertensive ischaemic ulcers are often misdiagnosed and can be a clinical and therapeutic challenge. Controversy exists regarding both their underlying triggers and the type of treatment that should be carried out. This study was designed to compare the effectiveness of punch grafting and conventional therapy in pain reduction. METHOD: A single-centre retrospective study was performed, including 40 patients with a clinical diagnosis of a Martorell ulcer or post-traumatic ulcer secondary to arteriolopathy in the elderly, who were treated with punch grafting (n= 24) or conventional medical treatment (n=16). RESULTS: There was a statistically and clinically significant reduction in pain after punch grafting. The minimal overall reduction was of three points in visual analogue pain scores. Of the patients who received punch grafting, 80% reported a VAS pain score of 0 at the third follow-up, in contrast with the 44% (n=4) patients who were treated without punch grafting. The mean time to epithelialisation was 82.1 days in patients who received conventional treatment and 43.5 days in those who received punch grafts. CONCLUSION: Punch grafting is a simple, validated and cost-effective technique that can be performed on an outpatient basis, promotes wound healing and reduces pain. It may control pain and stimulate epithelialisation even if the wound does not present with optimum wound bed characteristics for graft taking. Pain reduction and faster epithelialisation are associated with improvements in patients' quality of life.

Maternal, Perinatal and Neonatal Outcomes of Triplet Pregnancies According to Chorionicity: A Systematic Review of the Literature and Meta-Analysis.

Triplet pregnancies are rare events that affect approximately 93 in 100,000 deliveries in the world, especially due to the increased use of assisted reproductive techniques and older maternal age. Triplet pregnancies are associated with a higher risk of fetal and maternal morbidity and mortality compared to twins and singletons. Chorionicity has been proposed as a major determinant of perinatal and maternal outcomes in triplet pregnancies, although further evidence is needed to clarify the extent and real influence of this factor. Thus, the aim of this study was to conduct a systematic review of the literature and a meta-analysis of the maternal and perinatal outcomes of triplet pregnancies, evaluating how chorionicity may influence these results. A total of 46 studies with 43,653 triplet pregnancies and 128,145 live births were included. Among the main results of our study, we found a broad spectrum of fetal and maternal complications, especially in the group of monochorionic and dichorionic pregnancies. Risk of admission to NICU, respiratory distress, sepsis, necrotizing enterocolitis, perinatal and intrauterine mortality were all found to be higher in non-TCTA pregnancies than in TCTA pregnancies. To date, our meta-analysis includes the largest population sample and number of studies conducted in this field, evaluating a wide variety of outcome measures. The heterogeneity and retrospective design of the studies included in our research represent the main limitations of this review. More evidence is needed to fully assess outcome measures that could not be studied in this review due to scarcity of publications or insufficient sample size.