#and secondary causes resulting from endocrinopathies

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Know more about Diabetes Nursing at the 13NHPSUCG.

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Introduction of Diabetes Mellitus.

Diabetes mellitus is derived from the Latin term mellitus, which means sweet, and the Greek word diabetes, which means to syphon or pass through. The Latin word mellitus, which means sweet, and the Greek word diabetes, which means to syphon or pass through, are the origins of the term diabetes mellitus. The term "diabetes" is thought to have been created by Apollonius of Memphis between 250 and 300 BC. The sweet character of the urine in this illness was discovered by the ancient Greek, Indian, and Egyptian civilizations, leading to the spread of the term diabetes mellitus. In 1889, Miring and Murkowski made the discovery that the pancreas plays a part in the pathophysiology of diabetes. At the University of Toronto, Banting, Best, and Collop isolated the hormone insulin from the pancreas of cows in 1922, paving the way for the creation of a successful diabetic treatment. To address this expanding issue, great work has been done throughout the years, leading to several discoveries and the development of management techniques. Diabetes is regrettably still one of the most widespread chronic diseases in the nation and the world today. It continues to be the seventh most common cause of death in the US.

Diabetes mellitus (DM) is a metabolic condition marked by unnecessarily high blood glucose levels. Type 1, type 2, maturity-onset diabetes of the young (MODY), gestational diabetes, neonatal diabetes, and secondary causes resulting from endocrinopathies, steroid use, etc. are some of the different kinds of DM. Type 1 diabetes mellitus (T1DM) and Type 2 diabetes mellitus (T2DM) are the two primary subtypes of DM, and both are typically brought on by faulty insulin secretion (T1DM) and/or action (T2DM). T2DM is expected to affect middle-aged and older individuals who have chronic hyperglycemia as a result of poor lifestyle and nutritional choices, whereas T1DM is thought to manifest in children or teenagers. Since the pathophysiology of T1DM and T2DM is very diverse from one another, each type has a separate etiology, presentation, and course of treatment.

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MAS = Meconium Aspiration Syndrome, McCune-Albright Syndrome

McCune-Albright syndrome (MAS) is a rare disorder characterized by precocious gonadarche, polyostotic fibrous dysplasia of the bone*, and café au lait spots. Patients may also exhibit other endocrinopathies including hyperthyroidism, hyperadrenalism, Cushing syndrome, hypophosphatemic rickets and/or acromegaly. It is caused by a non-inherited somatic mutation in the G protein intracellular signaling system (GNAS1 gene) that leads to unregulated activation of adenylate cyclase and overproduction of several proteins in cells of the ovary, bone, and skin. The precocious gonadarche associated with McCune-Albright syndrome is a GnRH-independent or peripheral precocious puberty that results from ovarian hyperfunction and cyst formation, leading to episodic estrogen secretion. Patients will experience recurrent, unpredictable vaginal bleeding and breast development without growth of pubic hair (patients have excess estrogen activity without excess androgens). The classic boney lesion seen in MAS results from polyostotic fibrous dysplasia and is most commonly seen in long bones, ribs, and the skull on one side of the body. It may present with multiple fractures during early childhood, gait anomalies, visible bony deformities, and/or bone pain. Most patients with MAS will have multiple hyperpigmented cutaneous macules, also referred to as café au lait spots, which frequently predominate one side of the body without crossing the midline. Diagnosis involves a full endocrine evaluation including TSH, prolactin, cortisol, ACTH, gonadotropin and sex hormone levels. In females, estradiol levels will be elevated and GnRH levels will be low or normal. A GnRH stimulation test can be used to differentiate GnRH-dependent (central) from GnRH-independent (peripheral) precocious puberty and will show a suppressed LH response to GnRH. Imaging studies to consider include pelvic ultrasound (detects ovarian enlargement and cysts) and bone scan (detects fibrous dysplasia). Management varies depending on the endocrine abnormalities present. Precocious gonadarche is usually treated with anti-estrogens (tamoxifen), estrogen synthesis blockers (ketoconazole, testolactone), and/or medroxyprogesterone acetate. Bisphosphonates are commonly given to relieve pain and slow progression of fibrous dysplasia.

Bottom Line: McCune-Albright syndrome is caused by a gain-of-function mutation in the GNAS1 gene. The classic triad of symptoms associated with the disorder is fibrous dysplasia of bone, café-au-lait skin spots, and precocious puberty. Work-up includes evaluation of gonadal and endocrine hormone levels and a GnRH stimulation test. Treatment is dictated by the tissues affected and the extent to which they are affected. It usually includes an anti-androgen or anti-estrogen to control precocious puberty.

COMBANK Insight : The COMAT and COMLEX Level 2-CE will expect you to know the Tanner stages of pubertal development for both boys and girls. They may describe certain secondary sex characteristics and ask you to stage the patient or they may give you a stage and you must determine if the patient is developing appropriately. It is beneficial to learn what characteristics are associated with each stage and the ages that each stage is commonly seen in.

*Fibrous dysplasia is an uncommon bone disorder in which scar-like (fibrous) tissue develops in place of normal bone. This irregular tissue can weaken the affected bone and cause it to deform or fracture.

I think it’s annoying to memorize tanner stages. Even the residents I’m working with don’t have them memorized and have to check. She. They report a case, they say “Tanner 2 or 3, but I have to check.” Why do we need to memorize things that can be easily looked up?

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Endometrial scratch for infertile polycystic ovary syndrome (PCOS) women undergoing laparoscopic ovarian drilling: a randomized controlled trial

Abstract

Background - Women with polycystic ovarian syndrome (PCOS) may undergo laparoscopic ovarian drilling (LOD). To find out whether endometrial scratch, at time of LOD, could improve live birth rate in subfertile women with PCOS, a randomized controlled trial was conducted.

Results -There was no evidence of a significant difference in cumulative live birth rate between women who had endometrial scratch at time of LOD and those who had LOD only (38.1% and 34.3% respectively, odds ratio 1.18, 95% CI (0.67, 2.07); p = 0.57).

Conclusion - Women undergoing laparoscopic ovarian drilling should not be subjected to endometrial scratch as it does not lead to improvement in live birth rate. The study was prospectively registered on 25 April 2014 in ClinicalTrials.gov with identifier number NCT02140398.

Background

Polycystic ovarian syndrome is the most common cause of anovulatory subfertility [1]. Weight reduction, lifestyle modification, and ovulation induction are the recommended initial management strategies [2, 3]. Laparoscopic ovarian drilling (LOD) has been suggested to induce ovulation in these women, especially those who fail to ovulate through ovulatory medications [4,5,6]. It has been suggested that the procedure is as effective as ovarian stimulation with exogenous gonadotropins [7], yet it does not increase multiple pregnancy rates or ovarian hyperstimulation syndrome (OHSS) rates. Many women may ovulate after LOD, yet they fail to conceive [8]. Those women may need to undergo IVF treatment in their pursuit for a baby.

Endometrial scratching is a procedure where the endometrium is subjected to physical trauma that caused injury to the functional layer of the endometrium mechanically [9,10,11,12]. It has been suggested that endometrial injury could improve IVF outcome in women with recurrent implantation failure after IVF [13]. Nonetheless, endometrial scratch has been also proposed to overcome subfertility in women with unexplained infertility [14]. Randomized controlled trials have also shown improvements of intrauterine insemination (IUI) results in women subjected to controlled endometrial injury prior to insemination [9, 10]. However, there were some other studies that have shown no benefit from the procedure [15, 16].

The aim of our study was to find out whether performing endometrial scratch at time of laparoscopic drilling would improve live birth rate in subfertile women with PCOS. 

Patients and methods   

Study design and participants - We conducted a parallel randomized controlled trial (RCT), approved by our university ethics committee. We approached all infertile women with anovulatory infertility due to PCOS referred for laparoscopic ovarian drilling in Mansoura University Teaching Hospitals in Mansoura, Egypt. Our hospital is a tertiary care center conducting between 600 and 700 laparoscopic surgeries per year for infertile women. The study was conducted during the period from April 2014 to April 2015 (last patient enrollment). Follow-up was continued for 9 months after laparoscopy. The last pregnancy was in December 2015. Last data collection was in September 2016. An informed written consent was obtained from all women who participated in the study. 

Our inclusion criteria were women aged 20 and less than 39 and women with PCOS as diagnosed by Rotterdam criteria, fertile semen analysis according to WHO 2010, and bilateral tubal patency as demonstrated by hysterosalpingogram (HSG) [17, 18]. The exclusion criteria were suspected endometriosis, suspected uterine cavity anomaly or mass, associated male factor infertility, presence of endocrinopathy as thyroid dysfunction, and women subjected to endometrial curettage for any reason in the last 6 months.   

Intervention 

Women were admitted to our hospital 1 day before laparoscopic drilling. Women were randomized into two groups: group A (the intervention group) and group B (the control group). Randomization was through a computer-generated list of random numbers. Allocation of women to groups was through an opaque sealed envelope that had to be picked by a nurse in the operative theater. The surgeon was not blinded to the procedure while patients and data assessor were blinded to their allocation. 

All women underwent a three-puncture laparoscopy procedure where laparoscopic ovarian drilling (LOD) was achieved. Ovarian drilling was performed through monopolar coagulation diathermy. Four punctures were performed. Each penetrates about 4 mm depth, using 40-W power that lasts for 4 s. In the intervention group (group A), endometrial scratching was performed at the end of laparoscopy by endometrial curette. The curette was introduced gently through the cervix up to the uterine fundus then withdrawn for 1 or 2 cm. One act of scratching was performed on the posterior wall of the uterus after the end of drilling. The obtained specimens were sent for histopathology. The control group (group B) had LOD only, and no endometrial scratch was performed.   

Women in both groups were seen 3 months after laparoscopy and were asked whether they had a positive pregnancy test, still have oligomenorrhea, or had had regular periods. Women who had regular periods were subjected to folliculometry to confirm the establishment of ovulation while those with oligomenorrhea were subjected to ovulation induction with clomiphene citrate, tamoxifen, or letrozole. Women who did not respond to ovulatory oral medications were stimulated using exogenous gonadotropins using the low-dose step-up protocol with a 37.5 IU starting dose [19]. The primary outcome measure in this trial was live birth rate per woman randomized. Secondary outcome measures were clinical pregnancy rate, time to pregnancy, miscarriage rate, and multiple pregnancy rate. The study was registered in ClinicalTrials.gov with identifier number NCT02140398.

Definitions - Clinical pregnancy was defined as the presence of intrauterine gestational sac 1 or 2 weeks after positive pregnancy test in blood. Live birth was defined as the delivery of living fetus after 24 weeks gestation.

Statistical analysis - We estimated that the pregnancy rate after laparoscopic ovarian drilling was around 50% [20]. The intervention was suggested to boost pregnancy rate up to 70%. We calculated that we will need to study 93 experimental subjects and 93 control subjects to be able to reject the null hypothesis that the failure rates for experimental and control subjects are equal with a study power (probability) of 80%. The type I error probability associated with this test of this null hypothesis is 0.05 [21]. To compensate for dropouts, we calculated that we needed to randomize 210 women. We used SPSS 15 program. We adopted the intention-to-treat analysis.

Source -  https://mefj.springeropen.com/articles/10.1186/s43043-019-0001-2

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