XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

https://www.medpagetoday.com/upload/2014/3/3/02536-1.pdf

2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease

Jeffrey L. Anderson, MD, FACC, FAHA, Chair , Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect , Nancy M. Albert, PhD, CCNS, CCRN, FAHA, Biykem Bozkurt, MD, PhD, FACC, FAHA, Ralph G. Brindis, MD, MPH, MACC, Mark A. Creager, MD, FACC, FAHA[§§][1], Lesley H. Curtis, PhD, FAHA, David DeMets, PhD,

2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

1. Type 1 diabetes (due to b-cell destruction, usually leading to absolute insulin deficiency) 2. Type 2 diabetes (due to a progressive insulin secretory defect on the background of insulin resistance) 3. Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third trimester of pregnancy that is not clearly overt diabetes) 4. Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of the young [MODY]), diseases of the exocrine pancreas (such as cystic fibrosis), and drugor chemical-induced diabetes (such as in the treatment of HIV/AIDS or after organ transplantation)

Classification and diagnosis of diabetes



The World Health Organization’s call for elimination of cervical cancer envisages 70% screening coverage of women aged 35 and 45 years by an effective test. In India, this target seems unrealistic as awareness and access to cancer prevention services are poor. However, the institutional delivery rate is now >80%. We evaluated the acceptability and feasibility of human papillomavirus (HPV) testing and its role in screening during pregnancy.



This observational study recruited 275 pregnant women aged >25 years between 12 and 34 weeks of gestation for screening by cytology and HPV testing. Colposcopy was advised if either test was positive. Acceptability and feasibility were assessed by a questionnaire.



Cytology and HPV reports were available for 269 subjects. The median age was 28 years and median parity was two. Only 98 (36.4%) had heard about carcinoma cervix. Awareness improved with education (p<0.001). On cytology, only 4 (1.5%) were abnormal (atypical squamous cells of undetermined significance 3; low-grade squamous intraepithelial lesion 1). The prevalence of high-risk HPV infection was 8.2% (22/269). On colposcopy, all had the Swede score <5. No high-grade cervical intraepithelial neoplasia or carcinoma was detected. Pre-procedure, 183 (68.0%) subjects expressed apprehension, post-procedure 114 (42.4%) of them had realized that their apprehensions were unfounded. Women found screening to be more uncomfortable after 28 weeks of gestation (n=26/68; 38.2%; p<0.001). Physicians found the cervix more difficult to visualize after 20 weeks of gestation (p<0.001).



HPV screening at 16–20 weeks of pregnancy is acceptable, feasible, and can greatly improve screening coverage in resource-limited settings. Pregnancy is a good opportunity to improve awareness of the screening programmes.


Evaluation of cervical cancer screening during pregnancy in India: Human papillomavirus testing can change the paradigm

<h3>Introduction/Background</h3> Epithelial Ovarian cancer (EOC) usually metastasizes via direct, lymphatic and haematogenous routes and usual sites of spread are peritoneum, omentum and lymph nodes. Cutaneous metastases in EOC are relatively rare, with incidence reported to be 0.9–5.8%. However, more cases are being reported in recent literature, probably due to advancement in therapeutics. <h3>Methodology</h3> Records of patients with EOC who presented at a tertiary cancer care institute in India during the time period 2020–2022 were reviewed. The clinicopathological features, management and outcomes of patients with cutaneous metastasis were analysed. <h3>Results</h3> Three cases of cutaneous metastasis were identified, out of which one presented in the upfront setting and the other two in the recurrent. Age at presentation ranged from 39–74 years. All three had high grade serous adenocarcinomas. Patient in upfront setting presented with Sister Joseph nodule (SJN), with umbilical lump and discharge being the initial symptom. She underwent further investigations, neoadjuvant chemotherapy and surgical cytoreduction and umbilectomy, she is currently disease free after 1 year of treatment. In the other two cases, the cutaneous metastases presented as recurrent disease after 9 months and 8 years of completion of therapy, respectively. The sites of these metastasis were face and scalp respectively. Both the cases were managed using second line chemotherapy (gemcitabine, cisplatin, bevacuzimab) and are currently doing well. <h3>Conclusion</h3> Detailed history and meticulous systemic examination including skin examination can be crucial for early detection of metastasis from carcinoma ovary. while SJN is a well known entity, rare sites such as face and scalp should be kept in high index of suspicion. 

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2022-RA-1602-ESGO Cutaneous metastasis in epithelial ovarian cancer: experience from a tertiary care cancer institute

Herniation of ovaries and Mullerian structures into inguinal canal is usually reported in infants and is rare among adults. We are presenting a rare case of Mullerian agenesis and Turner mosaic syndrome with tubo-ovarian inguinal hernia.A 17-year-old girl presented with complaints of primary amenorrhea, phenotypical features of Turner syndrome with left inguinal hernia and severe hypertension. Baseline hormonal analysis was normal. Karyotype revealed Turner mosaic with 46XX (85%); 45XO (15%). MRI showed Mullerian agenesis with normally located right ovary in pelvis and left ovary prolapsed through deep inguinal ring into the canal of Nuck. Anti-hypertensives were started and patient optimized for surgery. Laparoscopic hernia repair and repositioning of left ovary into the pelvis was done. Patient had uneventful post-operative course and was discharged in stable condition on anti-hypertensive medication. Future reproductive issues and need of passive vaginal dilatation or vaginoplasty before marriage were explained to the patient and family.This is the first ever reported case with unusual association of atypical MRKH, Turner mosaic syndrome and tubo-ovarian hernia into the inguinal canal. The case emphasizes the need and importance of complete work up of these atypical cases as patients may have more than one cause of primary amenorrhea and complete evaluation is must before any medical or surgical intervention. 

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An unusual association of type II Mayer-Rokitansky-Kuster-Hauser syndrome, turner mosaic syndrome and tubo-ovarian inguinal hernia– case report and review of literature

Vidushi Kulshrestha is a Associate Professor, Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India; Shinjini Narang is an Ex-Senior Resident, Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India; Shalimar is an Additional Professor, Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi; and Neerja Bhatla is an Professor, Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India.

Rifampicin as an Adjunct to Ursodeoxycholic Acid for Treating Severe Refractory Intrahepatic Cholestasis of Pregnancy in a Patient with Elevated Bilirubin

The concept of circulating fetal cells in the mother was first discussed by a German pathologist, Georg Schmorl, who identified fetal trophoblasts in lungs of eclamptic women on autopsy in 1893 [1]. After this suggestion there was a hiatus of nearly 100 years before any development could be made in the field. Gradually, with the development of cell sorting techniques, separation of single cells was possible, and the further development of PCR and FISH techniques allowed the analysis of single cells. In the 1990s, there was a lot of interest in various methods for noninvasive prenatal diagnosis (NIPT) [2]. It was then that the paper on cell-free fetal DNA by Lo et al. generated great enthusiasm among the proponents of NIPT [3]. In this landmark study, circulating male fetal DNA was detecting in 80% of women carrying male fetuses using a sensitive Y-PCR assay. This paved the way for a revolution leading to its present day status having an undisputed stand among the tests for prenatal diagnosis.

Neerja Bhatla

Papers

Evaluation of cervical cancer screening during pregnancy in India: Human papillomavirus testing can change the paradigm

2022-RA-1602-ESGO Cutaneous metastasis in epithelial ovarian cancer: experience from a tertiary care cancer institute

An unusual association of type II Mayer-Rokitansky-Kuster-Hauser syndrome, turner mosaic syndrome and tubo-ovarian inguinal hernia– case report and review of literature

Rifampicin as an Adjunct to Ursodeoxycholic Acid for Treating Severe Refractory Intrahepatic Cholestasis of Pregnancy in a Patient with Elevated Bilirubin

Noninvasive Prenatal Testing (NIPT): Current Status