April 2022 – Student Nurse Life

Thyroid Gland Anatomy and Physiology

The thyroid gland is situated just below the larynx, with its right and left lateral lobes lying on either side of the trachea, connected together by the isthmus. It plays a major role in the metabolism, growth and development of the human body, regulating body functions by constantly releasing a steady amount of thyroid hormones into the bloodstream. It receives a rich blood supply of about 80 to 120ml per minute.

Thyroid Gland Histology

The thyroid gland is composed of spherical sacs called thyroid follicles which are covered by a wall made up of Follicular Cells and Parafollicular Cells a.k.a. C Cells.

Follicular Cells produce thyroxine (T₄) and triiodothyronine (T₃). Whilst T₄ is usually produced in greater quantities than T₃, T₃ is up to 4 times more potent than T₄. Additionally, about a third of T₃ is converted to T₄ within peripheral tissues, especially within the lungs and the liver.
Parafollicular Cells produce calcitonin (CT).

Thyroid Hormone Formation, Storage & Release

The thyroid gland is the only endocrine gland that stores its hormonal products in large quantities, eventually releasing them steadily over time. Thyroid hormone formation, storage and release occurs through the following process:

Iodide Trapping – iodide ions are actively transported from the blood to the follicular cells
Thyroglobulin Synthesis – during iodide ion trapping, follicular cells synthesise the glycoprotein Thyroglobulin (TGB) which is released into the thyroid follicle lumen by exocytosis, resulting in colloid accumulation within the lumen and Tyrosine (amino acids) iodination in TGB
Iodide Oxidation – iodide ions bind to TGB following oxidation; simultaneously, iodine is formed by the action of peroxidase
Tyrosine Iodination – formed iodine reacts with tyrosine in the colloid; one iodine atom binding forms monoiodotyrosine (T₁); a second iodine atom binding produces diiodotyrosine (T₂)
T₁ and T₂ Coupling – T₁ and T₂ join and form thyroid hormones
Colloid Pinocytosis & Digestion – colloid droplets re-enter the follicular cells though pinocytosis, and then merge with lysosomes in the follicular cells; lysozyme breaks down TGB, and then produce T₃ and T₄ molecules
Thyroid Hormone Secretion – lipid-soluble T₃ and T₄ diffuse through the plasma membrane into the interstitial fluid, and then into the blood; T₄ is secreted in larger quantities than T₃, yet T₃ is much more potent than T₄
Transport into Blood – Thyroxine-Binding Globulin (TBG) which is a transport protein found within the blood plasma combine with both T₃ and T₄ and are carried around in the body within the blood; when T₄ enters a cell, most of it is converted to T₃ following removal of one iodine

NOTE: Iodine supplements may be given to pregnant women and for compensation of hypothyroidism.

Thyroid Hormone Regulation

Thyroid hormone secretion is stimulated by various factors…

Calcitonin (CT)

Calcitonin, which is produced by the parafollicular cells of the thyroid gland, is involved in the homeostasis of blood calcium level:

Calcitonin inhibits bone breakdown and promotes bone calcium absorption
Calcitonin is used in the treatment of post-menopausal osteoporosis along with calcium and vitamin dietary intake
Calcitonin secretion is controlled via a negative feedback system

NOTE: Diarrhoea is a possible sign of increased thyroid hormone. Similarly, constipation is a possible sign of underactive thyroid.

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Diabetes Nursing Management of Complications and Preventative Care

Whilst diabetes preventative care can help avoid the development of type 2 diabetes mellitus, adequate diabetes nursing management can help avoid or reduce the occurrence of serious diabetes complications, such as short-term complications which include hypoglycaemia, diabetic ketoacidosis, hyperosmolar non-ketotic coma, as well as long-term complications which include microvascular and macrovascular complications, and neuropathy.

Short-Term Diabetes Complications

Hypoglycaemia

Hypoglycaemia can be defined as a glucose concentration of 3.9mmol/l or below.

diabetes nursing management — Retrieved from https://www.facebook.com/photo/?fbid=272975211310190&set=a.111544340786612 on 16th April 2022

An individual with hypoglycaemia can be asymptomatic, usually due to adaptation of the brain to chronic hypoglycaemia, which presents with symptoms even at normal blood sugar levels. This can be avoided if the individual experiences a few weeks of good glycaemic control.

An individual with hypoglycaemia may also present with mild symptoms which can be self-managed, severe symptoms requiring medical assistance, and even coma.

Hypoglycaemia Causes

insulin or sulphonylurea overdose (deliberate or accidental) – insulin can cause hypoglycaemia; metformin does not
inaccurate injection administration
renal and liver impairment cause pharmacokinetic change, possibly leading to a hypoglycaemic episode; individuals with renal and liver impairment should be monitored closely
delayed or forgotten meal, or insufficient carbohydrate intake
alcohol intake – food needs to be taken with alcohol, otherwise hypogycaemia can be triggered
exercise – can trigger a hypoglycaemic episode following exercise or even several hours after
hot weather or saunas – insulin is absorbed quicker in warmer temperatures, thus, saunas and hot weather should be avoided
honeymoon period (following diagnosis is usually a period a.k.a. honeymoon period in which remaining beta cells may pump out enough insulin to control blood glucose, thus may require less insulin)

Nursing Management of Hypoglycaemia

If the patient presents with mild hypoglycaemia:

give 15-20g of glucose such as a sugary drink – water with 2 teaspoons of sugar
repeat after 10 minutes
check if patient is still hypoglycaemic through HGT testing
if stable give a snack eg. brown bread sandwich to prevent recurrence

NOTE: sugar helps stabilise the patient for that moment; a snack helps maintain glucose level higher for a longer period of time.

If the patient is uncooperative:

Administer GlucoGel (formerly known as Hypostop – raises sugar levels quickly and provides a fast-acting energy boost in the form of Dextrose Gel – 40% dextrose).

NOTE: following a hypoglycaemic episode, ALWAYS ESTABLISH CAUSE eg. problem with insulin administration.

If the patient is unconscious:

adjust patient into the recovery position
administer glucagon by intramuscular or subcutaneous injection OR 50cc of 50% dextrose intravenously.

Preventative Measures

The older person is at increased risk of suffering from fall injuries, heart attacks and strokes during hypoglycaemic episodes. Thus, teach older adults at risk of hypoglycaemia:

to carry an ID bracelet at all times
to check their blood glucose levels prior to risky activities
to know and identify early signs of an impending hypoglycaemic episode

Diabetic Ketoacidosis

Diabetic Ketoacidosis is the most acute state of Type 1 Diabetes. Diabetic Ketoacidosis onset may be both gradual or sudden, and is characterised by the following findings:

hyperglycaemia (15.0mmol/l and over)
ketonuria (if cells are not supplied with enough glucose, the body burns fat for energy whilst producing ketones which can show up in the blood and urine, evident in a urine dipstick test)
pH of 7.3 or less (normal blood pH level is 7.35 to 7.45)

Common causes for DKA include:

infection – most common cause of DKA eg. gastroenteritis, flu, small infection etc.
stressors – traumatic injuries and/or increased stress
insulin cessation – common in adolescents; patients need to be reminded that diabetes is a condition for life, thus needs to be controlled with ongoing treatment
anuria (not passing urine) – a minimum of 30ml/hr of urine should be passed
not eating – increases risk of DKA

Retrieved from https://eliteayurveda.com/blog/3-main-symptoms-or-3ps-of-diabetes/ on 25th June 2022

Kussmaul Breathing

Kussmaul Breathing is a sign of DKA. It is characterised by sweet-smelling breath which is rapid and deep. It manifests as a compensatory mechanism due to build-up of carbon dioxide and lack of oxygen.

Diabetes Nursing Management of DKA

An individual with DKA needs:

treatment for hyperglycaemia – patient needs to be kept nil-by-mouth along with administration of a continuous low dosage of insulin by IV pump. NOTE: monitor blood glucose levels and ensure it isn’t lowered at a rate faster than 5mmol/hr to avoid cerebral oedema.
treatment for dehydration, electrolyte imbalance, and acidosis – patient needs administration of IV fluids with electrolytes (eg. Hartmann’s – a clear solution of sodium chloride, potassium chloride, calcium chloride dihydrate and sodium lactate 60% in water) to help with dehydration and electrolyte imbalance, and insulin, which usually also corrects acidosis without the need for sodium bicarbonate administration. NOTE: monitor serum potassium levels and ECG tracings to ensure correct potassium level is achieved, and monitor for signs of fluid overdose. NOTE: if not NBM, patient should be encouraged to drink high-carb drinks eg. broth, soup, juices etc.
treatment for precipitating factors – DKA is commonly induced by infection, thus, antibiotic therapy should begin following C&S specimen, wound drainage, or blood results are obtained.

NOTE: If patient is sick with flu/cold etc., blood glucose needs to be monitored, insulin needs to be administered still. Within the body, carbs start to be broken down in an attempt to avoid going into DKA. Monitoring carb intake to avoid going into hyperglycaemia is recommended.

Additionally, monitor frequently the patient’s:

vital signs: blood pressure, pulse, temperature, and respirations
level of consciousness
intake and output
urine
blood glucose
ketone bodies
GFR renal profile – to check kidney function and serum electrolytes
HbA1c – to monitor glucose for the past 3 months
CBC – to check volume of white blood cells (low white blood cell count may be a sign of infection which could have been the reason behind the patient going into DKA
ABGs, serum K levels, urea, and RBGs – to check the partial pressure of CO² and to see if the patient is going into respiratory acidosis; tests also give an indication of electrolyte status (eg. potassium is lost in DKA due to polyuria, and kidney function may become impaired, causing electrolyte imbalance)
ECG (due to risk of cardiac arrest from hypokalaemia)

and ensure that the patient:

receives mouth care due to NBM and dehydration
for dehydration encourage patient to drink water unless NBM, in which case, IV fluids should be administered – monitor fluid intake and output!
is cared for in case of pain (assess for need of analgesics), abdominal pain, nausea (administer antiemetics) and vomiting (provide vomiting bags just in case)
is kept safe (attention: side rails, frequent turnings, call bell at arms’ length, and skin care)
airway patency is maintained (if unconscious)
always provide reassurance (helps reduce patient anxiety)

DKA Possible Treatment Complications:

hypokalaemia
hypotension
dehydration
impaired renal function
cardiac arrest
HAIs – ensure proper infection control principles are maintained so as to avoid patient getting an infection (may already be infected since infection is one of the problems leading to DKA)

When DKA is resolved:

insulin is administered subcutaneously (insulin IV should be continued for 1hr following SC insulin injection)
food is provided 30 minutes following insulin administration
monitor for DKA recurrence
teach patient ways to prevent recurrence

Hyperosmolar Non-Ketotic Coma

Hyperosmolar non-ketotic coma usually happens in individuals who have not been diagnosed with diabetes, usually type 2 diabetes, and is more common in individuals over 60 years of age. Characteristics are usually less severe, and most commonly develop over a long period of time.

Characteristics of hyperosmolar non-ketotic coma include:

hyperglycaemia
dehydration
no ketoacidosis

Nursing Management of Hyperosmolar Non-Ketotic Coma

Patients with Hyperosmolar Non-Ketotic Coma need to be treated in the same way as in Diabetic Ketoacidosis EXCEPT:

if serum Na (Sodium) is MORE THAN 155mmol/l use 0.45% NaCl instead of 0.9% NaCl
patient may require insulin infusion at a lower rate
patient should be administered an anticoagulant due to an increased risk for thromboembolism
patient should have central venous pressure catheter

NOTE: following resolution, patient may require insulin subcutaneously for a few weeks before transitioning to new treatment regimen consisting of diet, exercise, and hypoglycaemic agents.

Long-Term Diabetes Complications

Microvascular Complications

Microvascular complications of diabetes are long-term complications which affect small blood vessels. Complications typically include:

retinopathy – retina disease (most common cause of blindness in young people)
nephropathy – kidney function deterioration (affects 45% of diabetic patients, 25% of which develop end-stage renal disease)
peripheral neuropathy – impaired sensation in the peripheries (feet and hands)
autonomic neuropathy – bowel and bladder disorders

MACROVASCULAR COMPLICATIONS

Macrovascular complications of Type 2 Diabetes are primarily diseases of the coronary arteries, peripheral arteries, and cerebrovasculature. Cardiovascular disease is the primary cause of death in diabetic patients. Early macrovascular disease is associated with atherosclerosis.

Preventative Measures for Microvascular and Macrovascular Complications

in patients with stable glycaemic control assess glycaemic status through A1C or other glycaemic measurements at least every 6 months
in patients with unstable glycaemic control and/or who have had recent treatment change assess glycaemic status through A1C at least every 3 months
promote lipid management through the Mediterranean Diet or DASH, reduction of saturated fat and trans fat intake, increase in healthy fats intake, viscous fiber, plant sterols intake (found in vegetable oils, nuts and seeds), and increased physical activity to prevent atherosclerosis development
promote optimum glycaemic control in patients with triglyceride levels of >150mg/dL (1.7mmol/L) and low HDL Cholesterol amounting to <40mg/dL (1.0mmol/L) in men and <50mg/dL (1.3mmol/L) in women
screen for renal disease at least yearly through urinary-albumin-to-creatinine ratio and estimated glomerular filtration rate (EGFR) in individuals with 5 years or more of type 1 diabetes, and in all individuals with type 2 diabetes (monitor every 6 months patients with >300mg/g creatinine and EGFR 30-60mL/min/1.73m²)
refer to ophthalmologist for eye complication screening patients with type 1 diabetes within 5 years of diabetes diagnosis, and patients with type 2 diabetes upon diabetes diagnosis
provide general preventative diabetic foot self-care education to all patients with diabetes, and refer to registered podiatrist for annual foot evaluation to identify risk factors for ulcer formation and amputations

Statin Therapy

Retrieved from https://www.uchealth.org/ on 23rd April 2022

CVD Risk Assessment Tool for Healthcare Professionals

ESC CVD Risk Calculation App (Apple or Android)

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Female Reproductive System

The female reproductive system consists of the following organs:

ovaries – produce secondary oocytes and hormones (progesterone, oestrogens, relaxin, and inhibin)
fallopian tubes – the sites where fertilisation normally occurs; additionally assist in transporting a secondary oocyte to the uterus
uterus – cavity in which a fertilised ovum implants, and develops into a fetus for pregnancy and labour
vagina – the site which receives the penis during sexual intercourse, and which acts as a passageway during childbirth
external organs / vulva / pudendum

The Ovaries

The ovaries are a pair of irregularly scarred surfaced pale white glands measuring between 2.5 to 3.5cm long, 2cm wide, and 1.25cm thick. They produce gametes, which are secondary oocytes that develop into mature ova following fertilisation, and the hormones oestrogen, progesterone, inhibin, and relaxin.

The ovaries are held in place by 3 types of ligaments, namely the broad ligament of the uterus, which is part of the parietal peritoneum that attaches to the ovaries by the mesovarium; the ovarian ligament, which anchors the ovaries to the uterus; and the suspensory ligament, which attaches the ovaries to the pelvic walls.

Each ovary consists of:

GERMINAL EPITHELIUM – a layer of simple epithelium which covers the ovary’s surface and is continuous with the mesothelium that covers the mesovarium. The germinal epithelium does not give rise to ova.

TUNICA ALBUGINEA – a whitish capsule of dense irregular connective tissue found right beneath the germinal epithelium.

OVARIAN CORTEX – consists of ovarian follicles which are surrounded by dense irregular connective tissue containing scattered smooth muscle cells. The ovarian cortex can be found right beneath the tunica albuginea.

OVARIAN MEDULLA – consists of loose connective tissue which contains blood vessels, lymphatic vessels, and nerves.

OVARIAN FOLLICLES – consist of oocytes in various developing phases and surrounding cells which provide nourishment to the oocytes and secrete oestrogens throughout the follicle’s growing phase; single-layered surrounding cells are referred to as follicular cells, while multiple-layered surrounding cells are referred to as granulosa cells.

GRAAFIAN FOLLICLE – large follicle full of fluid in a close-to-being-ruptured state.

CORPUS LUTEUM – contains the remnants of the mature follicle, following ovulation; the corpus luteum produces progesterone, oestrogens, relaxin, and inhibin, before turning into fibrous scar tissue referred to as the corpus albicans.

Retrieved from https://slideplayer.com/slide/8162919/ on 15th April 2022

The Fallopian Tubes

The fallopian tubes are two hollow fibromuscular cylinders lined by epithelium which extend outwards and backwards around 10cm from the uterine cornu to the ovaries. Each fallopian tube is divided into the following parts:

interstitial (approx. 0.7mm x 2.5cm)
isthmus (approx. 1mm x 2.5cm)
ampulla (approx. 6mm x 5cm)
infundibulum (approx. 10mm wide)

The fallopian tubes are made up of 3 layers:

INTERNAL MUCOSA – contains ciliated columnar epithelial cells that help move the fertilised ovum along the tube.

MUSCULARIS – is the middle layer. It is composed of an inner circular ring of smooth muscle and an outer thin region of longitudinal smooth muscle; peristaltic contractions of the muscularis along with the ciliary action of the mucosal cells assist the oocyte or fertilised ovum to move towards the uterus.

SEROSA – the outer layer of the fallopian tubes.

The Uterus

The uterus is a pear-shaped hollow organ that projects anteriorly and superiorly over the urinary bladder, measuring about 7.5cm x 5cm at the fundus, and 2.5cm from front to back. The uterine wall thickness measures around 1 to 2cm.

The uterus features the following anatomical subdivisions:

fundus – dome-shaped portion superior to the fallopian tubes
body – tapering entral portion
cervix – inferior narrow portion which opens into the vagina; projects inferiorly and posteriorly, and enters the vaginal wall at almost a right angle
isthmus – constricted region measuring around 1cm long found between the body and the cervix

The uterine cavity is the uterine body’s inferior. The cervical canal is the interior of the narrow cervix. The cervical canal opens into the uterine cavity at the internal os into the vagina at the external os.

The uterus is made up of 3 layers:

PERIMETRIUM – the outer layer of the uterus becomes the broad ligament laterally, covers the urinary bladder and forms the vesicouterine pouch anteriorly, and covers the rectum and forms the rectouterine pouch a.k.a. pouch of Douglas posteriorly.

MYOMETRIUM – the middle layer of the uterus is thickest and circular in the fundus area and the thinnest and longitudinal in the cervix area; the myometrium responds to oxytocin released by the pituitary during labour and childbirth through contraction coordination which help in expelling the fetus from the uterus.

ENDOMETRIUM – the inner layer of the uterus is highly vascular. It is divided into two layers: the stratum functionalis lines the uterine cavity and sloughs off during menstruation, and the stratum basalis, which is a permanent layer, gives rise to a new stratum functionalis following each menstruation.

Retrieved from https://socratic.org/questions/what-are-the-two-layers-of-the-endometrium on 15th April 2022

Cervical Mucus

Cervical mucus is a secretion produced by the secretory cells of the cervix’s mucosa. It consists of water, glycoprotein, lipids, enzymes, and inorganic salts. Females in their fertile years secrete between 20-60ml of cervical mucus daily, which is more hospitable to sperm at or close to ovulation, when it is less viscous and increasingly alkaline with a pH of 8.5. Viscous mucus forms the cervical plug which stops sperm penetration.

The Vagina

The vagina is a long tubular fibromuscular canal measuring approximately 10cm long which extends from the exterior of the body to the cervix. It acts as a receptacle for the penis during sexual intercourse, an outlet for menstruation, and a passageway during childbirth.

The vaginal mucosa, which is continuous with the uterine mucosa, contains large glycogen stores that, upon decomposing, produce organic acids, which lead to a resulting acidic environment which retards microbial growth.

The Vulva

The vulva a.k.a. pudendum, is the female’s external genitalia. It consists of the following:

mons pubis
labia majora
labia minora
clitoris

Retrieved from https://www.cancer.org/cancer/vulvar-cancer/about/what-is-vulvar-cancer.html on 15th April 2022

Mammary Glands

The mammary glands, which lie over the pectoralis major and the serratus anterior, are modified sweat glands which produce milk.

Functions of the breast in relation to lactation include:

milk synthesis
milk secretion
milk ejection

NIPPLE – pigmented projection.

LACTIFEROUS DUCTS – closely spaced duct openings which allow milk ejection.

AREOLA – circular rough-looking pigmented area surrounding the nipple which contains modified sebaceous glands.

SUSPENSORY LIGAMENTS OF THE BREAST A.K.A. COOPER’S LIGAMENTS – strands of connective tissue found between the skin and the deep fascia that provides support for the breast.

MILK – following production, milk passes from the milk-secreting alveoli into secondary tubules, and then into mammary ducts. Mammary ducts close to the nipple expand and form lactiferous sinuses, where milk is stored, and is eventually drained into the lactiferous ducts, which drain into the exterior.

Retrieved from https://www.brainkart.com/article/Mammary-Glands—Anatomy-and-Physiology_18849/ on 16th April 2022

Hormones Related to the Female Reproductive System

Follicle-Stimulating Hormone (FSH)

in females initiates the development of an ova every month, and stimulates cells within the ovaries to secrete oestrogens
in males stimulates the testes to produce sperm
secretion depends on the hypothalamic regulating factor gonadotropin releasing factor (GnRF), which is released in response to oestrogens in females, and to testosterone in males through a negative feedback system

Luteinizing Hormone (LH)

along with oestrogens, in females it stimulates the release of an ovum within the ovary, prepares the uterus for the implantation of the fertilised ovum, stimulates the formation of the corpus luteum in the ovary to secrete progesterone, and prepares the mammary glands for milk secretion
in males it stimulates the interstitial endocrinocytes in the testes to develop and secrete testosterone
secretion is controlled by GnRF, which works through a negative feedback system

Prolactin (PRL)

requires priming of the mammary glands through oestrogens, progesterone, corticosteroids, growth hormone, thyroxine, and insulin
initiates and maintains milk secretion by the mammary glands (amount of milk is determined by oxytocin)
has an inhibitory and an excitatory negative control system
level rises during pregnancy, falls right after delivery, and rises again during breastfeeding, which is why in the 1st two days following birth, mothers do not produce milk but colostrum

NOTE: women on oral contraceptives may experience lack of milk production due to their hormonal effect.

Pituitary Gland Posterior Lobe

The posterior lobe of the pituitary gland a.k.a. neurohypophysis, does not synthesise hormones. It releases hormones to the circulation via the posterior hypophyseal veins to be distributed to target cells in other tissues. The cell bodies of the neurosecretory cells produce Oxytocin (OT) and Antidiuretic Hormone (ADH) / Vasopressin.

Oxytocin (OT)

is released in high amounts just before birth
stimulates contraction of smooth muscle cells in the pregnant uterus
stimulates the contractile cells around the mammary gland ducts
affects milk ejection
works through a positive feedback cycle which is broken following birthing
is inhibited by progesterone, but can work in conjunction to oestrogens

The Female Reproductive Cycle

The female reproductive cycle a.k.a. menstrual cycle demonstrates regular cyclic changes seeming as periodic preparations for fertilisation and pregnancy, which, if unsuccessful, results in menstruation where the uterine mucosa (stratum functionalis portion of the endometrium) is shed.

The ovarian cycle features a series of events related to the maturation of an ovum which usually occurs on a monthly basis.

Oestrogen

Oestrogen assists in the development and maintenance of the endometrial lining of the uterus, secondary sex characteristics, and breasts
Oestrogen helps keep fluid and electrolyte balance
Oestrogen increases protein anabolism (process in which amino acids are transformed into proteins) and is synergistic with the Growth Hormone a.k.a. Somatotropin
Oestrogen helps in keeping a low blood cholesterol level

NOTE: Moderate levels of oestrogens in the blood inhibit GnRF (Gonadotropin-Releasing Hormone) release by the hypothalamus. This causes the inhibition of FSH (Follicle Stimulating Hormone) secretion by the anterior pituitary gland.

pROGESTERONE

Progesterone works in conjunction with Oestrogen in preparing the endometrium for implantation of a fertilised ovum, and in preparation of the mammary glands for milk secretion

NOTE: High levels of progesterone inhibit GnRF (Gonadotropin-Releasing Hormone) and LH (Luteinizing Hormone).

Inhibin

Inhibin inhibits the secretion of FSH (Follicle Stimulating Hormone) and LH (Luteinizing Hormone). This happens so as to inhibit multiple ovum maturation following the release of a mature ovum following ovulation.

Relaxin

Relaxin helps relax the uterus through the inhibition of myometrium contractions
Relaxin is produced by the placenta during pregnancy to help increase relaxation of the uterine smooth muscle
Relaxin increases the flexibility of the pubic symphysis near the end of pregnancy, and may also help in the cervix dilation process in preparation for childbirth

The Menstrual Cycle

Retrieved from https://sofreshnsogreen.com/wellness/cycle-syncing-guide/ on 16th April 2022

The menstrual cycle can be divided into 3 phases:

THE MENSTRUAL PHASE – the periodic discharge of 25ml to 65ml of blood, tissue fluid, mucus and epithelial cells, caused by a sudden reduction in oestrogens and progesterone. This phase usually lasts for around 5 days.

During this phase, 20 to 25 primary follicles start to produce small amounts of oestrogens.
By the end of menstruation, around 20 of these primary follicles develop into secondary follicles, while surrounding cells increase in number, differentiate, and secrete follicular fluid.
The follicular fluid forces an immature ovum to the edge of the secondary follicle and fills the follicular cavity, whilst secondary follicles produce oestrogens, leading to an elevation of oestrogen levels in the blood.
Ovarian follicle development results from GnRF secretion by the hypothalamus, which then stimulates high FSH production by the anterior pituitary.

THE PREOVULATORY PHASE – the second phase of the menstrual cycle which covers the phase between menstruation and ovulation.

FSH and LH stimulate ovarian follicles to increase oestrogen production, which stimulates the rebuilding of the endometrium, which by the end of this phase doubles to up to 6mm.
With the thickening of the endometrium, short straight endometrial glands develop, and arterioles coil and lengthen whilst penetrating the functionalis.
LH is secreted in increasing quantities as this phase starts to near its end.
A secondary follicle matures into a vesicular ovarian a.k.a. graafian follicle, ready for ovulation. At this time, just before ovulation occurs, the vesicular ovarian starts producing small amounts of progesterone.

OVULATION – the immature ovum in the vesicular ovarian follicle is released into the pelvic cavity around the middle of the menstrual cycle.

Immediately prior to ovulation, high levels of oestrogen inhibit GnRF production by the hypothalamus, which in turn inhibits FSH secretion by the anterior pituitary via a negative feedback effect.
At the same time, high levels of oestrogen work through a positive feedback effect, causing the anterior pituitary to release a high amount of LH which triggers ovulation.
Following ovulation, the vesicular ovarian follicle collapses, the follicular cells enlarge, change, and form the corpus luteum.

THE POSTOVULATORY PHASE – represents the time between ovulation and onset of upcoming menses. This phase is consistent in duration.

Following ovulation, LH secretion stimulates the development of the corpus luteum.
The corpus luteum secretes increasing quantities of oestrogens and progesterone.
FSH secretion increases gradually whilst LH secretion decreases.
During this phase, progesterone becomes the most dominant ovarian hormone.

SEQUELAE

If fertilisation and implantation do not occur, the increasing progesterone and oestrogen levels secreted by the corpus luteum inhibit GnRF and LH secretion.
The corpus luteum degenerates, which causes decreased secretion of progesterone and oestrogens.
The corpus luteum becomes the corpus albicans, whilst the decrease in progesterone and oestrogens trigger another menstrual cycle to begin, along with increased output of GnRF by the hypothalamus and a new output of FSH.

Retrieved from https://quizlet.com/au/232342424/hormonal-control-of-menstrual-cycle-diagram/ on 16th April 2022

Conditions & Operations Related to the Female Reproductive System

Hysterectomy

Hysterectomy is the most common gynaecological operation, commonly indicated in endometriosis, pelvic inflammatory disease, recurrent ovarian cysts, excessive uterine bleeding, and cancer of the cervix, uterus, or ovaries.

There are 3 types of hysterectomies:

Total Hysterectomy – removal of the uterine body and cervix
Partial Hysterectomy – removal of uterine body only (cervix is left in situ)
Radical Hysterectomy – removal of uterine body, cervix, fallopian tubes (and possibly the ovaries), the vagina’s superior portion, the pelvic lymph nodes, and supporting structures

Retrieved from https://www.gleneagles.com.sg/specialties/medical-specialties/women-gynaecology/hysterectomy on 15th April 2022

Cystocoele

Cystocoele is a herniation of the bladder wall into the vaginal cavity.

Rectocoele

Rectocoele is a herniation of the rectum into the vaginal wall.

Retrieved from https://fascrs.org/patients/diseases-and-conditions/a-z/rectocele-expanded-information on 14th April 2022

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Male Reproductive System

The male reproductive system consists of the following organs:

testes
ducts system (ductus deferens, ejaculatory ducts, urethra)
accessory sex glands (seminal vesicles, prostate gland, bulbourethral gland)
supporting structures (scrotum, penis)

The function of the testes is to produce sperm and secrete hormones, while the ducts system is responsible for the transportation and storage of sperm, assistance in sperm maturation, as well as conveyance of the sperm to the exterior.

male reproductive system — Retrieved from https://www.slideserve.com/coy/chapter-28-the-reproductive-systems on 5th April 2022

The Scrotum

The scrotum acts as a supporting structure for the testes, consisting of loose skin and superficial fascia that hangs from the root of the penis. The left testis is suspended lower than the right testis. The spermatic cord passes up the scrotum’s back, through the inguinal ring, and into the pelvic cavity.

The external structure of the scrotum consists of rich sensory innervation, sebaceous glands, darker pigmentation, and sparse hair.

Within the internal structure of the scrotum is the scrotal septum (made up of the superficial fascia and the dartos muscle), which divides the scrotum into 2 sacs.

The testes are kept cooler by the following 3 structures:

cremaster muscle of the spermatic cord – relaxes when warm, contracts when cool, thus raising or lowering the scrotum and testes
dartos muscle in the scrotal wall – contracts and tautens the scrotum when cool
pampiniform plexus of blood vessels in the spermatic cord – acts as countercurrent heat exchanger, cooling blood on its way to the testis

The Testes

The testes are paired oval glands measuring around 5cm long with a diameter of 2.5cm. Each testis weighs between 10-15g. During foetal development, the testes originate near the kidneys, from where they start descending through the inguinal canals towards and into the scrotum by the end of the 7th month of pregnancy.

The testis has a fibrous capsule known as Tunica Albuginea. Within the fibrous septa are up to 300 compartments known as lobules, each of which contains up to 3 sperm-producing seminiferous tubules. Between these tubules are clusters of interstitial cells which secrete testosterone.

Retrieved from https://radiopaedia.org/cases/testis-cross-section?lang=us on 5th April 2022

The Seminiferous Tubules

The seminiferous tubules contain the following two types of cells:

spermatogenic cells – produce sperm
sertoli cells – support spermatogenesis

Sertoli Cells

Sertoli cells, a.k.a. sustentacular cells, support and protect spermatogenic cells through their development.

Retrieved from https://www.nagwa.com/en/videos/104129276305/ on 5th April 2022

Leydig Cells

Leydig cells a.k.a. interstitial endocrinocytes, are found in clusters within the spaces between adjacent seminiferous tubules. They secrete testosterone.

Retrieved from https://histology.siu.edu/erg/RE028b.htm on 7th April 2022

The Ducts

Sperm cells pass through a number of ducts to exit the body. Once they leave the testes, sperm cells pass through the epididymis, ductus deferens, ejaculatory duct, and urethra.

EFFERENT DUCTULES – carry sperm from the posterior side of the testis to the epididymis thanks to ciliated cell clusters which assist the sperm through.

EPIDIDYMIS – whilst travelling through the epididymis, sperm cells mature, and are then stored in the epididymis’s tail, where they remain fertile for 40 to 60 days.

DUCTUS DEFERENS – sperm cells travel from the epididymis’s tail before uniting with the seminal vesicle duct.

EJACULATORY DUCT – allows the sperm cells through the prostate gland before emptying into the urethra.

SEMINIFEROUS TUBULES – open up into a collection of very short ducts known as straight tubules, which lead into the rete testis.

EFFERENT DUCTS – sperm moves into a series of coiled ducts within the epididymis.

DUCTUS EPIDIDYMIS – efferent ducts empty into a single tube a.k.a. ductus epididymis.

Retrieved from https://quizlet.com/213934544/chapter-27-male-reproductive-system-flash-cards/ on 7th April 2022

Accessory Sex Glands within the Male Reproductive System

Seminal Vesicles

Seminal Vesicles are a pair of glands associated with the ductus deferens, posterior to the urinary bladder base and anterior to the rectum. Seminal vesicles secrete an alkaline yellowish secretion, which helps in neutralising the acidic environment of the male urethra and the female reproductive tract. It totals about 60% of semen, containing Fructose (used for sperm ATP production), Prostaglandins (provide sperm motility and viability), and Clotting Proteins (promote semen coagulation following ejaculation).

Prostate Gland

The prostate gland is a single gland situated immediately inferior to the bladder, surrounding the urethra and the ejaculatory duct. It secretes a thin, milky, slightly acidic secretion totaling around 30% of semen, containing Citric Acid (used for sperm ATP production via Krebs’ cycle), Proteolytic Enzymes (promote breakdown of clotting proteins from the seminal vesicles), and Acid Phosphatase.

Bulbourethral a.k.a. cowper glands

Bulbourethral Glands a.k.a. Cowper’s Glands, are pea-sized glands located posterior to the prostate. They produce a clear, slippery fluid during sexual arousal, which helps lubricate the penis’s head in preparation for intercourse. It also neutralises the acidity of residual urine found in the urethra, since this acidity would be harmful to the sperm.

The Penis

The penis provides a passageway for sperm ejaculation and urine excretion through the urethra. It consists of the Root (attached portion), the Body (2 corpora cavernosa, and 1 corpus spongiosum), and the Glans penis.

Hormones related to the Male Reproductive System

ANDROGENS – masculinising steroid sex hormones eg. testosterone (normally secreted in both sexes)

OESTROGENS – feminising steroid sex hormones (normally secreted in both sexes)

PITUITARY GONADOTROPHINS – FSH (follicle-stimulating hormone) helps in maintaining spermatogenic epithelium and sertoli cells within the male, and LH (luteinizing hormone) stimulates testosterone production from the Leydig Cells within the testes.

Testosterone

Testosterone, which is the primary hormone in the testes:

promotes male development
is responsible for an inhibitory feedback response on the pituitary’s secretion of LH
develops and maintains male secondary sex characteristics eg. body hair growth, larynx enlargement and voice deepening, increased stature, etc.
exerts a protein anabolic, growth-promoting effect
maintains gametogenesis, along with FSH

Testicular Function Control

FSH:

maintains gametogenic function, along with androgens
is tropic to the Sertoli cells
stimulates secretion of androgen-binding protein and inhibin (inhibin feeds back to inhibit FSH secretion)

LH:

stimulates testosterone secretion (testosterone feeds back to inhibit LH secretion)
is tropic to the Leydig cells

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Infection Control Measures in Immunosuppressed Patients

Infection complications are most often predictable and possibly preventable through adequate infection control measures. In immunosuppressed patients this is of high importance, especially since the greater the impairment, the higher the risk of infection. Recognising patients with increased risk, identifying and correcting risk factors in advance, and reducing sources of infection are important aspects related to prevention of infection.

Immunosuppressed Patients

Immunosuppressed patients typically are those patients who have:

extensive burns
organ transplants
particular genetic disorders eg. immunoglobulin A deficiency
HIV infections
leukaemias (cancer of white blood cells)
lymphomas (cancer of the lymphatic system)
high-dose chemotherapy
haematological malignancies (cancers originating in blood-forming tissue eg. bone marrow, or in immune system cells)
neutropenia (lack of neutrophils)

Neutropenia

Neutropenia is characterised by lack of neutrophils – white blood cells that help fight infections, especially those caused by bacteria. Normal range for neutrophils is 2.5-7.5 x 10⁹/L. The lower the neutrophil count, the steeper the fall or the longer the duration of neutropenia, the higher the risk of infection.

immunosuppressed patients — Retrieved from https://www.haematologica.org/article/view/7075 on 2nd April 2022

Protective Precautions vs Protective Isolation

COMMENSAL MICRO-ORGANISMS – can be found on body surfaces which are covered by epithelial cells and exposed to the external environment (GI tract, respiration tract, vagina, skin, etc).

COMMENSAL BACTERIA – although co-evolved with their hosts, in specific circumstances can overcome protective responses in the host, causing pathologic effects.

NOSOCOMIAL INFECTIONS – eg. healthcare associated infections & MRSA.

OPPORTUNISTIC INFECTIONS – infections affecting solely the immunosuppressed patient eg. Kaposi’s sarcoma.

Infection-causing micro-organisms in immunosuppressed patients may be acquired through:

the presence of the individual’s normal flora
hospital staff hands
hospital equipment
food

Protective isolation components include:

physical separation from the main population through the use of a single room
restriction on movement, visitors and diet
antimicrobial prophylaxis and selective decontamination of the digestive system
care for the maintenance of skin and mucous membrane integrity
application of hand hygiene to prevent exogenous acquisition of micro-organisms

NOTE: Signs & symptoms of infection are most commonly absent in immunosuppressed patients.

Transferring an immunosuppressed patient in Protective Isolation may not be enough to prevent subsequent development of infection.

Infection Control Measures

Infection control measures help prevent infection in immunosuppressed patients. Standard precautions should be applied when caring for neutropenic patients as well as severely immunosuppressed patients.

Component	Recommendations
Hand hygiene	after contact with body fluids (including contaminated items), after glove removal, and between one patient and another
Gloves	use when touching body fluids (including contaminated items), when touching mucous membranes, and non-intact skin
Gown	use during procedures and patient care which require contact with clothing and exposed skin with anticipated exposure to body fluid
Face protection (eg. masks, goggles, visors)	use during procedures and patient care which are likely to generate splashes of body fluids, including aerosol-generating procedures with suspected or proven infections that transmit by respiratory aerosols (in which case wear an N95 or higher respirator along with gloves, gown, face and eye protection)
Soiled equipment	handle using preventative measures to avoid transferring micro-organisms to other individuals and to the environment; perform hand hygiene and wear gloves when handling visibly contaminated items
Environmental control	support/advocate for routine care, cleaning and disinfection of surroundings, especially surroundings close to patient-care areas

Standard Precautions

Textiles and laundry	handle using preventative measures to avoid transferring micro-organisms to other individuals and to the environment
Sharps	avoid recapping, bending, breaking or manipulating used needles; if recapping is needed, use one-hand scoop technique; use safety features if available; use appropriate sharps disposal containers
Patient resuscitation	use mouthpiece, resuscitation bag, or other ventilation devices to prevent oral contact and contact with oral secretions
Patient placement	use single-patient room if patient is at increased risk of transmission, contamination, lacking hygiene maintenance, or if patient is at increased risk of becoming infected or developing adverse outcomes following infection
Hygiene etiquiette	teach symptomatic patients to cover mouth and nose when sneezing and coughing, correct use and disposal of tissues, wearing of surgical mask if tolerated, or maintaining spatial separation (if possible more than 3 feet)

Patient Placement

SINGLE ROOM – promotes reinforcement of infection control measures; should be prioritised for isolating individuals with communicable diseases or epidemiologically important organisms, to avoid exposing immunosuppressed patients to such organisms. A patient placed in a single room should:

have an isolation notice displayed on the door
have an ensuite bathroom
have its door closed at all times
have limited staff entering the room
be provided with psychological support and reassurance whilst in isolation
not have staff with infections to provide patient care
not have staff to provide patient care whilst providing care to infectious patients in the same duty shift

SINGLE ROOM + HIGH EFFICIENCY PARTICULATE AIR (HEPA) FILTERS – promote reduction of risk to healthcare associated infections due to airborne fungi such as Aspergillus Genus (especially where construction-related work is in progress).

Patient Hygiene

FATIGUE – Immunosuppressed patients are often fatigued. Thus, patient hygiene must be assessed on a daily basis, and assistance must be provided where necessary.

PERINEAL CARE – Immunosuppressed patients frequently suffer from irritation or infection in the perineal area – an area which would be heavily colonised with bacteria. Thus, particular attention to this area is a must to maintain patient hygiene. Note that the use of soap may irritate the mucous membranes, leading to irritation exacerbation.

STAFF ILLNESS – immunosuppressed patients should not be nursed by staff with known or suspected infections or communicable diseases eg. oral-facial herpes simplex and upper respiratory tract infections; contact between such individuals should be reported to the infection control team and to the patient’s medical consultant.

Hand Hygiene

Environment and Equipment

Removal of dust from surfaces may help prevent infection (routine use of chemical disinfectant has not yet been proven to reduce infection) – surfaces need to be damp-dusted daily with single use cleaning cloths and neutral detergent; mop head needs to be laundered daily
Isolation rooms require cleaning with the use of gloves and aprons, followed by hand hygiene prior to leaving the room
Vacated rooms must be cleaned thoroughly before they are reoccupied
Medical equipment should be decontaminated after each use
Single-use items must be discarded and not re-used
Toys of immunosuppressed children should be decontaminated
Flowers and plants have not been directly linked to infection in immunosuppressed patients, however, are usually not permitted since they may act as a reservoir for Gram Negative bacteria or fungal spores like Aspergillus

Personal protective equipment

Use of face masks is not known to prevent infection in immunosuppressed patients, but can help protect healthcare staff from body fluid splashing
Routine use of non-sterile gloves and aprons/gowns may help in preventing acquisition of micro-organisms
PPEs must be minimally used to prevent contact with body fluids or contaminated items, and when in contact with non-intact skin and mucous membranes
Must be removed and discarded of as clinical waste after use, followed by application of hand hygiene
Sterile gloves are only required in certain aseptic or invasive procedures, or when in contact with sterile sites

Nutrition

Immunosuppressed patients have an increased risk of acquiring food-borne illnesses and harmful micro-organisms, and so, should be advised to avoid high-risk foods such as shellfish, pate’, soft cheeses and foods that are made with raw eggs
Neutropenic individuals have an increased risk of acquiring infection from Gram-Negative bacteria which is commonly found in sink plugholes and overflow outlets

Immunosuppressed Patient Visitors

Visitors should:

report to a staff member prior to entering the patient’s room so precautions can be explained, and infections that may pose danger for the patient may be identified
not visit if they have any transmissible infection
not bring any pets, and plants or flowers (fresh or dried)

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Metabolic Syndrome and Obesity

Obesity is a disease which involves excessive body fat that increases the risk of additional diseases and health issues, such as cardiovascular disease, diabetes, hypertension, and cancer. Metabolic syndrome is closely linked to obesity and inactivity, as well as insulin resistance.

Retrieved from https://twitter.com/gainalliance/status/854273300389916672?lang=bn on 28th March 2022

Obesity

Obesity is “a chronic relapsing progressive disease progress” (Bray et al., 2017). It is determined by the following factors:

Energy Balance
Obesogenic Environment
Nature VS Nurture

eNERGY BALANCE

Energy In (dietary intake) VS Energy Out (physical activity)

Obesogenic Environment

An environment that promotes weight gain and is not conducive to weight loss.

Nature vs Nurture

Genes affect the metabolic rate, fuel use, brain chemistry, and body shape. Over-eating is learned earlier on in childhood eg. encouraging child to eat whatever is on the plate. Environmental factors add to weight gain influences. Social status affects weight status eg. poverty may lead to unhealthy food choices.

Nutrition Assessment of Obesity

Obesity is characterised by excessive body fat: women with >35% body fat and men with >25% body fat. Excessive body fat puts the individual at increased risk for health problems. Body fat is calculated by measuring skin folds using calipers.

BMI calculation = weight (kg) / height (m²). BMI should ideally be between 18.5 and 24.9kg/m²

Retrieved from https://bjcardio.co.uk/2014/11/obesity-module-1-management-in-primary-care/4/ on 28th March 2022

Retrieved from https://www.researchgate.net/publication/346569912_Obesity_Weight_Loss_and_Cardiovascular_Risk/figures?lo=1&utm_source=google&utm_medium=organic on 28th March 2022

Obesity Health Risks

(Adapted from Bray GA. Gray DS, Obesity, part 1: Pathogenesis. West J Med 149:429, 1988; and Lew EA, Garfinkle L; Variations in mortality by weight among 750,000 men and women. J Clin Epidemiol 32:563, 1979.) Retrieved from https://slideplayer.com/slide/5330508/ on 28th March 2022

Android vs Gynoid Body Fat Distribution

ANDROID

obesity centered in the upper-body area – apple shape
abdominal fat is released into the liver
associated with cardiovascular disease, hypertension and type 2 diabetes
related hormone at play – testosterone

GYNOID

obesity centered in the lower-body area – pear shape
not as risky as android
related hormones at play – estrogen and progesterone

Retrieved from http://www.myhealthywaist.org/index.php?id=56&tx_nurebook_pi1[page]=9&cHash=644d9e5b11 on 28th March 2022

Health Problems Associated with Obesity

cardiovascular disease
hypertension
type 2 diabetes
pulmonary disease
cancer of the breast,colon, pancreas and gallbladder
sleep apnea
gallstones
bone/joint disorders
infertility
difficult delivery following pregnancy
increased surgical risk
reduced agility
poor quality of life
early death

Retrieved from https://slidetodoc.com/obesity-pathophysiology-risk-assessment-and-prevalence-obesity-excessive/ on 29th March 2022

In women, the incidence of coronary heart disease increased with increasing body mass index levels for both age groups. Among women older than 50 years, the heaviest group experienced 292 incidents of coronary heart disease compared with 223 in the BMI group < 25. In women younger than 50 years of age, the group of 30+ BMI experienced 179 incidents compared with only 76 in the < 25 BMI category. BMI Levels. Adapted from Hubert HB et al. Circulation 1983;67: Metropolitan Relative Weight of 110 is a BMI of approximately 25. Retrieved from https://slideplayer.com/slide/5330508/ on 29th March 2022

Obesity as an independent risk factor for cardiovascular disease was reexamined by Helen Hubert in the 5,209 men and women of the original Framingham cohort. Observations of disease occurrence over the 26 years indicate that obesity was an independent predictor of CVD, particularly among the younger members of the cohort and in women more than men. This study also showed that weight gain after the young adult years conveyed an increased risk of CVD in both sexes that could not be attributed to the initial weight or the levels of the risk factors that may have resulted from the weight gain. This slide shows the increasing incidence of coronary heart disease with increasing body mass index levels for both age groups of men. However, the gradient of risk was steeper among the younger men and women (< 50 years) . Among men younger than 50 years, the heaviest group experienced twice the risk of coronary disease compared with the leanest group. BMI Levels. Retrieved from https://slideplayer.com/slide/12116399/ on 29th March 2022

Weight Loss Benefits & Guidelines

Metabolic Syndrome and Obesity — Retrieved from https://community.jennycraig.com/healthy-habits-blog/live-life/10-ways-losing-5-10-of-your-body-weight-may-benefit-your-health/ on 29th March 2022

Adult Weight Loss…

total energy intake should be less than energy expenditure
consider diets with 600kcal/day deficit
consider low-fat diets alongside expert support and follow-ups for sustainable weight loss
keep in mind that low-calorie diets may not provide all nutritional requirements
include behaviour change strategies using a biopsychosocial approach and history in relation to past diet experiences as well as comorbidities

Metabolic Syndrome

Metabolic syndrome is a worldwide growing epidemic, affecting about 1 of every 4 or 5 adults in every country. Its incidence increases with age.

The term Metabolic Syndrome refers to a group of risk factors which increase the risk for cardiovascular disease, diabetes, stroke, and other health-related problems.

Metabolic Syndrome Risk Factors

hyperglycaemia
hypertension
abdominal obesity a.k.a. android obesity
low HDL cholesterol level
high triglyceride level (including individuals on treatment for high triglyceride level)

WHO Recommendations

Insulin Resistance

While a third of all individuals with Metabolic Syndrome have normal insulin sensitivity, the two are still associated with each other. Insulin resistance features high plasma insulin concentration which fails to suppress plasma glucose as normally happens. Contributing factors include unresponsiveness to insulin at a cellular level due to receptor-based mechanisms.

Hypertension

Insulin resistance and hyperinsulinaemia may cause hypertension due to an increase in catecholamine activity, as happens with increased insulin concentration through insulin-mediated renal tubular reabsorption of sodium. Weight loss helps in improving both hypertension and hyperinsulinaemia.

Dyslipidaemia

High trygliceride and low HDL cholesterol levels are key factors for metabolic syndrome, both commonly leading to cardiovascular disease. The term dyslipidemia refers to an increase in plasma cholesterol, triglycerides, both, or low HDL cholesterol level which leads to atherosclerosis development.

Preventing or Reversing Metabolic Syndrome

weight loss through healthy eating
regular exercise
smoking cessation
alcohol cessation
pharmacological interventions

Reference

Bray, G.A., Kim, K.K., & Wilding, J.P.H. (2017). Obesity: a chronic relapsing progressive disease process. A position statement of the World Obesity Federation. Obesity Reviews, 18: 715-723.

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