Evidence based research on Gonadotropin releasing hormone analog treatment in children with congenital adrenal hyperplasia complicated by central precocious puberty

Evidencebased research on Gonadotropin releasing hormone analog treatment inchildren with congenital adrenal hyperplasia complicated by centralprecocious puberty

Evidencebased research

Quantitative article: Gonadotropin releasing hormone analog treatment in children with congenital adrenal hyperplasia complicated by central precocious puberty

Background Information or Introduction

A patient who has congenital adrenal hyperplasia has high levels of androgens in the body that compromises the growth and thus height of the patient. This means that the patient’s heights are somehow smaller than expected. Elevated level of androgen also leads to the alteration of the bone ages with loss of the growth potential which results in the decreased growth in the patients.

Hyperandrogenemia, a situation where there is high amount of androgen, triggers and thus activation the hypothalamic pituitary which causes the central precocious puberty.

Gonadotropic releasing hormone analogs in most places are used to effectively treat central precocious puberty. It works by inhibiting further secretion of the androgen from adrenal cortex. This then results in the decreased amount of androgen in the circulation in the body. (SS, 2016)

Therefore this experiment serves to determine the effect of Gonadotropin releasing hormone analog on growth in patients with congenital adrenal hyperplasia complicates by central precocious puberty. (Andreyko JL, 2016)

Review of the Literature

In most places the congenital adrenal hyperplasia results in the excess secretion of the adrenal hormone of which our main hormone of concern is the androgen hormone together with the Luteinizing hormone and follicle stimulating hormone. These hormone especially androgen has effect on the growth and development thus leading to retard growth.

Gonadotropic releasing hormone leads to release of the androgen together with the luteinizing hormones and follicle stimulating hormone. Therefore gonadotropic releasing hormone analog will affect the secretion of these hormones.

In the experiment the analog is researched as to if it can manage the reduced growth exhibited by the highly produced androgen.

Discussion of methodology

Methodology

  • The patients that were used after admissions were taken through some tests and the detailed clinical histories of the patients were obtained and anthropometric measurements taken with light clothing using a digital scale and Harpenden stasiometer.

  • Body mass index was then calculated as a ration of weight and height squared.

  • Physical examination was also carried out to the patients and the records made as per the patient to help in assessment during later stages.

  • In female there is assessments of the breast developments according to the Tanner staging during the pubertal stages of the patients. On the other hand male physical assessments are done on the testis. Precocious puberty was defined as a situation in which there is enlarged testis and larger breast growth before the age of nine as for the boys and the age of eight for the girls.

  • Bone age assessment was carried out using the Greulich and Pyle method. In this case the target height was calculated at diagnosis such they are used in diagnostic purposes. The ratio of the bone age to chronological age was assessed at diagnosis at initiation of the gonadotrophic releasing hormone analog therapy.

The assessment involved a number of activities being carried out.

Endocrine work up

In this case it involved obtaining the blood sample from the patients except those who were salt wasting. The blood sample was then analyzed for the level of the androgen and the adrenocorticotropic hormone.

Gonadotropin releasing hormone stimulating test was also carried out on the patient except those having the central precocious puberty. Luteinizing hormone realizing hormone was then administered and the sample for luteinizing hormone and the follicle stimulating hormones was tested.

In this case the luteinizing hormone level if above 5mlU/ml then the patient has the pubertal.

The association of the central precocious puberty is also assessed in relation to the luteinizing hormone and follicle stimulating hormone as being more than 0.3

Imaging studies

In this case there is examination of the ovarian volume by the use of the ultrasonography.

Pituitary and cranial magnetic resonance imaging was also performed although to the eight patients with the central precocious puberty.

Mutation Analysis

The patients were checked for the any aspect of mutation by going through the mutation analysis of the special gene called CYP21A2 gene.

Therapy and follow up

In this case the patients’ were treated with the e hydrocortisone. Mineralocorticoid treatment was also added in two patients and the treatment was expected to be life-long.

Indication of the treatment with gonadotropic releasing hormone analog were follow

All patients who had CAH complicated by CPP were examined at 3 month intervals.

Also bone age, growth velocity of the person, and the body mass indexes of the patient were examined during the treatment application.

Data Analysis

All statistics to be obtained were then analyzed by the help of the SPSS 18 statistic package program to evaluate them.

Comparison was carried out by the paired Wilcoxon test. In this case the comparison was determined between various values obtained from the patient.

Correlation analysis and correlation coefficient was determined by the Spearman’s correlation method.

The significance was evaluated at p&lt0.05

In this research twelve of the patients were used. They were administered with various components like the gonadotropic releasing hormone analog. (Andreyko JL, 2016)

According to the results, individuals with 46XX karyotype ended up having the increased penile length. Four girls had clitoromegaly and one girl had clitoroplasty.

The diagnostic work was late owing to the fact that there was no neonatal screening to test for CAH.

Almost all the patients were seen having the CAH on their first admission and were treated as soon as it could be held possible. There were also aspects of the Hyperandrogenemia with some of them having CPP on their first admission

Three patients had the increased basal and stimulated gonadotropin level consistent with CPP and were immediately started on gonadotropic releasing hormone analog for treatment.

Gonadotropic releasing hormone analog therapy affects growth velocity and that height of the patient at diagnosis was inversely proportional with the ratio of bone age to chronological age.

Therefore, CAH patient with advanced bone agent time of diagnosis and decreased growth velocity which was consisted with a previous research project. Decreased bone age to chronological age ratio in the patient after treatment suggests that fact that gonadotrophic releasing hormone analog treatment usually slows down bonne age in patients with CAH complicated by CPP which could help improve linear growth.

Testis enlarges in the male and breast development are promotes since CAH caused by 21-hydroxylase deficiency together with the gonadotropic releasing hormone analog in addition to hydrocortisone and fludrocortisone.

Administration of the gonadotropic releasing hormone suppresses luteinizing hormone and follicle stimulating hormone

In consistence with other results, gonadotropic releasing hormone analog observed in the CAH patients causes insignificant improvement of the linear growth

Researcher conclusion

The present study demonstrates that CPP can be observed at a time of diagnosis in patients.

Central precocious puberty can be a complication of CAH mainly in the countries where routine neonatal screening takes place is lacking that is it is not used.

Bone age at diagnosis and at the beginning of gonadotropic releasing hormone analog is the important factor for growth velocity in patients with CAH complicated with CPP.

Gonadotropic releasing hormone analog alone can slow down bone age advancement resulting in a slight improvement in PAH. (Andreyko JL, 2016)

QuestionA and A2: Conclusion and the other bits

Conclusionentails the fact that the patient had the decreased rate of thegrowth and development as a result of the Hyperandrogenemia. The useof the gonadotropic releasing hormone analog helps in the managementof the situation. In this case, these patients present themselveshaving a high concentration of the androgen in the blood due to theadrenal hyperplasia. The excess androgen then causes reduced rate ofgrowth of the patient by reducing the capability of the cells togrow. Therefore, bone growth is greatly reduced.

Gonadotropicreleasing hormone analog tends to reduce these effects. Theproduction of the androgen from the adrenal gland depends on thehypothalamus-pituitary and adrenal gland correlation also termed asthe axis. The gonadotropic releasing hormone analog works just as thegonadotropic releasing hormone. The analog elicit negative feedbackto the axis that causes a shift in the amount of the androgenproduction. The analog causes the reduction in the production of theandrogen hormone in the blood despite the fact that the adrenal glandthat produces this hormone is defective. A remarkable decrease in theamount of androgen causes the reduction in the suppression action ofthe hormone to growth. (SS,2016)

Onthe other hand excess of the androgen hormones leads to enlargementof the testis of the boys while girls experience the breastdevelopment that is too rapid. This is because androgen is a sexhormone mainly involved with the sexual maturity and development ofsecondary characteristics. Therefore, when it exceed as in thissituation, the children tends to have the enlarged testis for maleand large breast in female.

Gonadotropicreleasing hormone analog also causes the effect in the amount of theluteinizing hormone and follicle stimulating hormone produced. Theyare regulated by the analog which elicit negative feedback mechanismsthat suppress the production of these hormones.

Ethicsto be considered

Theresearcher, in order to be ethical, needs to observe a lot of theissues so that he or she may carry out the research lawfully. Ethical principles refer to the codes that the researcher needs totake caution of in the course of their operation with the patient.They need to observe some few aspects for the respect of the patient.(&quot7Ethical Principles of Nursing | Wilkes Nursing Online&quot, 2016)

Helpfulness

Therule of usefulness aids the moral hypothesis to do what is great.This need to &quotdo great&quot makes a moral point of view andconceivable answer for a moral difficulty satisfactory. This standardis additionally identified with the guideline of utility, whichexpresses that we ought to endeavor to produce the biggest proportionof good over wickedness conceivable on the planet. This guidelinestipulates that moral hypotheses ought to endeavor to accomplish thebest measure of good since individual’s advantage from thegreatest. This standard is for the most part connected with theutilitarian moral hypothesis found in the accompanying segment ofthis paper. A case of &quotdoing great&quot is found in the act ofprescription in which the strength of an individual is bettered bytreatment from a doctor.

MinimumHarm

Thisis like helpfulness, however, manages circumstances in which neitherone of the choices is valuable. For this situation, a man ought to dothe slightest damage conceivable and to do mischief to the leastindividuals. Case in point, in the Hippocratic vow, a doctor isinitially accused of the obligation to &quotdo no damage&quot tothe patient since the doctor`s essential obligation is to giveaccommodating treatment to the patient as opposed to delivering allthe more enduring upon the patient.

Onecould likewise sensibly contend that individuals have a moreprominent obligation to &quotdo no damage&quot than to find a wayto advantage others. For instance, a man has a bigger obligation tojust stroll past a man as opposed to punching a man as they strollpast with no legitimized reason.

Regardfor Autonomy

Thisrule expresses that a moral hypothesis ought to permit individuals torule over themselves and to have the capacity to settle on choicesthat apply to their lives. This implies individuals ought to havecontrol over their lives however much as could reasonably be expectedin light of the fact that they are the main individuals who totallycomprehend their picked sort of way of life. Every man merits regardon the grounds that exclusive he has had those precise backgroundsand comprehends his feelings, inspirations, and body in such aprivate way. Basically, this moral rule is an augmentation of themoral standard of helpfulness in light of the fact that a man who isautonomous ordinarily likes to have control over his backgroundskeeping in mind the end goal to acquire the way of life that heappreciates.

Thereare, be that as it may, two methods for taking a gander at theappreciation for independence. In the paternalistic perspective, apower organizes a needy individual`s best advantages over the reliantindividual`s desires. For instance, a patient with terminal growthmay want to carry on with whatever remains of her existence withoutthe solution that makes her always sick. The doctor, then again, maypersuade the patient and her relatives to make the patient keeptaking her drug in light of the fact that the solution will draw outher life. In this circumstance, the doctor utilizes his or her powerto control the patient to pick the treatment that will advantage himor her best therapeutically. As noted in this case, one downside ofthis rule is that the paternalistic figure might not have the samestandards as the needy individual and will deny the patient`sself-rule and capacity to pick her treatment. This, thus, prompts adiminished measure of advantage.

Asecond route in which to see the appreciation for self-governance isthe libertarian view. This point of view organizes the patient`sdesires over their best advantages. This implies the patient hascontrol over her life and ought to be content with her personalsatisfaction since she has picked the way of existence with the bestmeasure of individual value. Despite the fact that this perspectiveis more aware of the patient`s longings, it doesn`t keep the patientfrom settling on choices that might be more unsafe than useful.

Equity

Theequity moral rule expresses that moral speculations ought torecommend activities that are reasonable to those included. Thisimplies moral choices ought to be predictable with the moralhypothesis unless special conditions that can be advocated exist forthe situation. This likewise implies cases with uncontrollable issuesat hand must contain a huge and basic distinction from comparativecases that legitimize the conflicting choice. A moral choice thatcontains equity inside it has a steady coherent premise that backingsthe choice. For instance, a policeman is permitted to speed on theparkway in the event that he should touch base at the scene of awrongdoing as fast as could be expected under the circumstanceskeeping in mind the end goal to keep a man from getting hurt. Inspite of the fact that the policeman would typically need to complywith as far as possible, he is permitted to speed in this novelcircumstance since it is a supported under the special conditions.

Strengthand weakness of the study

Despitethe achievement that was attained, the study that was carried out hadnumerous strength and weaknesses. The strength helps in the makingthe process to go on while the weaknesses were like discouraging bitof the study.

Strengths

Thestrength of the experiment is the fact that the results are obtainedjust as they are required since the patients are around the hospitalset up. The patients can be accessed easily for the collection of thedata needed for the evaluation in the study. They are easily takencare of thus leading to the even accurate result being obtainedduring the study.

Availabilityof the patient close to the place of study reduces the other costthat may be incurred like transport to the places to take the record.This thus leads to a researcher at all the time being in close rangeof the patient. Any slight change can be easily noticed.

Availabilityof the needed resources including the high technologized equipmentfacilitates recording of the data. This, therefore, means that theneeded information to be collected is accurately collected by aseries of this equipment. The collection process becomes easy andefficient thus leading to attaining of the needed results and correctevaluation of the study making it a successful.

Weakness

Itis not in all situations where the patients were required to offerthe concert. This, therefore, means that the rights of the patientswere jeopardized. The patients feel that they are not respected andare undermined. They become uneasy to the researcher which thenaffects the results obtained. Inaccurate analysis will therefore bemade.

Capitalburden also causes the weakening of the study. This is becausewithout the capital it will not be possible to have the equipment anddrugs needed to do the tasks. The study will stop if no alternativemeasures are taken into consideration. It, therefore, a weakness thestudy taking place.

Thedrugs like the gonadotropic releasing hormone analog are usuallyassociated with other side effects which they may jeopardize theresults recorded. To some patient, they may not be possible towithstand the analog for as long as possible thus they die offreducing the total population to a fewer amount that may not beconvenient. Reduction in the population reduces the consistency ofthe results obtained thus undermining the accuracy. (Kumar&amp Sharma, 2014)

Howevidence informs nursing skills

Theresults obtained impact on the nursing practice through various ways.These ways includes

• Understandingwhat patients, colleagues, families and careers can expect fromnursing as far as the health state of the patient is in play.

• Helpyou reflect on your practice and develop as a professional as the oneacquire essential skills that are necessary for the handling of thepatient and the result keeping that are collected in diagnosisprocedures. In this case evaluation of the results is also done thusequipping the nurse with that practice.

• Generatediscussions with your colleagues or if you are a student with yourmentor, tutor or fellow students on the aspects of behavior, attitudeand approach that underpin good nursing care at the end of it all.

• Identifywhere the principles are being practiced within your organization,and to identify instances where you think they are not beingpracticed. This is an important nursing practice acquired in theseprocesses. The principles are internalized and the nurse is inposition to clearly tell which principle should be applied at suchcircumstance. They cannot confuse between the various principles andpractices to be used.

• Seehow they relate to a trust’s own set of nursing values.This isto say that these impacts in the nursing practice to a way thatnurses are in position to win the patients trust easily. They knowwhat is expected to win the trust of the patient. This is essentialin nursing the patient to provide good care to them.

• Evaluatethe care they have received by using them as a checklist.

Qualitative Research: Gonadotropin releasing hormone analog treatment in children with congenital adrenal hyperplasia complicated by central precocious puberty

Background Information

Hyperandrogenemia, a situation where there is high amount of androgen, triggers and thus activation the hypothalamic pituitary which causes the central precocious puberty.

A patient who is having congenital adrenal hyperplasia has high levels of androgens in the body that compromises the growth and thus height of the patient.(SS, 2016)

Review of the Literature

In many spots the inherent adrenal hyperplasia results in the abundance discharge of the adrenal hormone of which our principle hormone of concern is the androgen hormone together with the Luteinizing hormone and follicle fortifying hormone. These hormone particularly androgen has impact on the development and improvement subsequently prompting hinder development.

Gonadotropic discharging hormone prompts arrival of the androgen together with the luteinizing hormones and follicle empowering hormone. Hence gonadotropic discharging hormone simple will influence the emission of these hormones.

In the analysis the simple is scrutinized as to on the off chance that it can deal with the diminished development displayed by the exceedingly delivered androgen.

Discussion of methodology

Methodology

• The patients that were used after admissions were taken through some tests and the detailed clinical histories of the patients were obtained and anthropometric measurements taken with light clothing using a digital scale and Harpenden stasiometer.

• Body mass index was then calculated as a ration of weight and height squared.

• Physical examination was also carried out to the patients and the records made as per the patient to help in assessment during later stages.

• In female there is assessments of the breast developments according to the Tanner staging during the pubertal stages of the patients. On the other hand male physical assessments are done on the testis. Precocious puberty was defined as a situation in which there is enlarged testis and larger breast growth before the age of nine as for the boys and the age of eight for the girls.

• Bone age assessment was carried out using the Greulich and Pyle method. In this case the target height was calculated at diagnosis such they are used in diagnostic purposes. The ratio of the bone age to chronological age was assessed at diagnosis at initiation of the gonadotrophic releasing hormone analog therapy.

The assessment involved a number of activities being carried out.

Endocrine work up

Imaging studies

In this case there is examination of the ovarian volume by the use of the ultrasonography.

Pituitary and cranial magnetic resonance imaging was also performed although to the eight patients with the central precocious puberty.

Mutation Analysis

The patients were checked for the any aspect of mutation by going through the mutation analysis of the special gene called CYP21A2 gene.

Therapy and follow up

In this case the patients’ were treated with the e hydrocortisone. Mineralocorticoid treatment was also added in two patients and the treatment was expected to be life-long.

Indication of the treatment with gonadotropic releasing hormone analog were follow

All patients who had CAH complicated by CPP were examined at 3 month intervals.

Also bone age, growth velocity of the person, and the body mass indexes of the patient were examined during the treatment application.

Data Analysis

All statistics to be obtained were then analyzed by the help of the SPSS 18 statistic package program to evaluate them.

Comparison was carried out by the paired Wilcoxon test. In this case the comparison was determined between various values obtained from the patient.

Correlation analysis and correlation coefficient was determined by the Spearman’s correlation method.

The significance was evaluated at p&lt0.05

In this research twelve of the patients were used. They were administered with various components like the gonadotropic releasing hormone analog

According to the results, individuals with 46XX karyotype ended up having the increased penile length. Four girls had clitoromegaly and one girl had clitoroplasty.

The diagnostic work was late owing to the fact that there was no neonatal screening to test for CAH.

Almost all the patients were seen having the CAH on their first admission and were treated as soon as it could be held possible. There were also aspects of the Hyperandrogenemia with some of them having CPP on their first admission

Three patients had the increased basal and stimulated gonadotropin level consistent with CPP and were immediately started on gonadotropic releasing hormone analog for treatment.

Gonadotropic releasing hormone analog therapy affects growth velocity and that height of the patient at diagnosis was inversely proportional with the ratio of bone age to chronological age.(Andreyko JL, 2016)

Therefore, CAH patient with advanced bone agent time of diagnosis and decreased growth velocity which was consisted with a previous research project. Decreased bone age to chronological age ratio in the patient after treatment suggests that fact that gonadotrophic releasing hormone analog treatment usually slows down bonne age in patients with CAH complicated by CPP which could help improve linear growth.

Testis enlarges in the male and breast development are promotes since CAH caused by 21-hydroxylase deficiency together with the gonadotropic releasing hormone analog in addition to hydrocortisone and fludrocortisone.

Administration of the gonadotropic releasing hormone suppresses luteinizing hormone and follicle stimulating hormone

In consistence with other results, gonadotropic releasing hormone analog observed in the CAH patients causes insignificant improvement of the linear growth.(Andreyko JL, 2016)

Researcher’s Conclusion

The present study exhibits that CPP can be seen during an era of determination in patients.

Focal intelligent pubescence can be an intricacy of CAH predominantly in the nations where routine neonatal screening happens is inadequate with regards to that is it is not utilized.

Bone age at determination and toward the start of gonadotropic discharging hormone simple is the vital variable for development speed in patients with CAH entangled with CPP.

Gonadotropic discharging hormone simple alone can back off bone age progression bringing about a slight change in PAH.

Whetherthe evidence support the conclusion

Accordingto the evidence provide in the data and the analysis carried out itis evident that the researcher conclusion is being supported by thearticles. This is seen owing to the fact that both the article andthe conclusion drawn are on the same basis that is aspect ofgonadotropic releasing hormone analog increasing the growth that wasinhibited by the CAH and CPP. The conclusion in fact is bestexplained in other part of the article including the working of thegonadotropic releasing hormone analog.

Protectionof human subjects and cultural consideration

Inthis context, the aspect of the rights of the patient is highlyrespected. The nursing activities of these patients entails taking ofthe consent before doing anything to them. They have the authoritynot to be used for the research purposes. This is to say that theyare the one to decide if they can be used for the research or not.They are not forced to.

Alsoadministration of drugs to these patients requires an informedconsent in which the patients know everything to which they are goingto pass through even if it’s the side effect. They then decidewhether to do or not.

Asfar as the research is taking place the cultural practices of thepatient is respected. The things that should be done on them shouldalso be in accordance to the culture like if the culture does notallow intravenous drug administration then it should not be done butinstead oral option to be used.

Inconclusion therefore the research always aims at respecting theopinions of the patient. They have rights and therefore the ethicalpractices as seen should be in play.

Strengthand weakness of the study

Thequalitative research is boosted by the factors such as thewillingness of the patient to cooperate with the researcher at alltime. This makes it possible to evaluate and analyze a wider range ofresults thus increasing the chances of the accuracy that is needed.At the end of it all a high quality and accurate conclusion isachieved. Numerous data collection also serves to strengthen thisstudy. With numerous data, it is possible to pin out variations thatoccurs during the research.

Lackof capital and other facilities is the major weakness for thisresearch activity. These are the components that are needed for theresearch to continue. Therefore shortage of any will greatlyundermine the research. The results at the end of the day may not becollected or if collected, it will most likely be inaccurate.

Application

Thisactivity serves to instill new skills in nursing practices such thatit won’t be a problem in working in the hospital set up. The skillsin nursing activities attained during the research are like recordkeeping which is due to keeping the record of the patient in theresearch work. There is also analysis of the results obtained thuskeeping on in position to attain the practice of analyzing theresult.

Workingwith the patients involves proper taking good care of them. Thispractice helps a lot in hospital set ups in managing and caring forthe patients admitted in that hospital. Therefore due to this it isfor sure that research evidence offers skills and enable in attainingthe practices essential in various other places be it in hospital oreven at homes.

References

AndreykoJL, e. (2016). Therapeuticuses of gonadotropin-releasing hormone analogs. – PubMed – NCBI.Ncbi.nlm.nih.gov.Retrieved 22 June 2016, fromhttp://www.ncbi.nlm.nih.gov/pubmed/3543765

Bio.davidson.edu.(2016). Principlesand Theories.Retrieved 22 June 2016, fromhttp://www.bio.davidson.edu/people/kabernd/indep/carainbow/theories.htm

Fraser,H.M, Lunn ,S. F, Morris, K. D, Deghenghi, R. I. (1997). Initiationof high dose gonadotrophin-releasing hormone antagonist treatmentduring the late follicular phase in the macaque abolishes lutealfunction irrespective of effects upon the luteinizing hormone surge.Hum.Reprod. 12,430–5.

Kumar,P. &amp Sharma, A. (2014). Gonadotropin-releasing hormone analogs:Understanding advantages and limitations. JHum Reprod Sci,7(3),170.

SS,Y. (2016). Clinicalapplications of gonadotropin-releasing hormone andgonadotropin-releasing hormone analogs. – PubMed – NCBI.Ncbi.nlm.nih.gov.Retrieved 22 June 2016, fromhttp://www.ncbi.nlm.nih.gov/pubmed/6130985

WilkesNursing Online.(2016). 7Ethical Principles of Nursing. Retrieved22 June 2016, fromhttp://onlinenursing.wilkes.edu/key-ethical-principles-of-nursing/