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Key Principles of Dorothea Orem’s Self-Care Model

Dorothea Orem’s Self-Care Model is one of the general theories of nursing that focuses on promoting self-care in the clinical environment. Specifically, the theory emphasizes the importance of self-reliance and personal responsibility in addressing the healthcare needs of individuals and families and defines nursing as interactions between two or more persons, including a nursing specialist, aimed at improving these capacities (Hagran & Fakharany, 2015). The approach identifies three types of self-care requisites: universal, developmental, and health deviation. The first one refers to the factors that are essential for ensuring the proper functioning of the human body, such as sufficient consumption of food, water, and air, provision of necessary care related to elimination processes, a healthy balance between physical activity and rest, adequate socialization, and the avoidance of potential risks and hazards (Hagran & Fakharany, 2015). On the other hand, developmental requisites are associated with processes caused by a variety of events and conditions, such as adjusting to a new environment or body changes. Lastly, health deviation requisites occur due to illnesses and injuries that negatively influence the functioning of the human being and hinder one’s self-care abilities temporarily or permanently (Silva, et al., 2009). They include receiving necessary medical assistance, understanding and accepting specific health conditions and their impact and consequences, carrying out prescribed treatment and regulating its uncomfortable effects, and learning to lead a productive life under the given circumstances.

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Most importantly, the model utilizes the principle of health care deficit to determine when nursing interventions are required to address the mentioned requisites and offers effective solutions. Specifically, the approach implies that nursing is needed when individuals have significantly limited self-care capabilities that prevent them from ensuring sufficient self-care on a constant basis. In such cases, the appropriate nursing interventions include the provision of necessary care, guidance, support, and education as well as the establishment of an environment that could promote personal development and satisfy future demands in the long-term (Hagran & Fakharany, 2015). The model also identifies three nursing systems that could be utilized to address the health care deficits of individuals: wholly compensatory, partly compensatory, and supportive-education.

Rationale for Selecting Dorothea Orem’s Self-Care Model

The lack of self-care knowledge and skills represents one of the most problematic issues in the modern clinical environment due to changing demographics. Specifically, the overall aging of populations worldwide in the last decades has contributed to the significant increase in the number of patients with chronic health conditions. According to research conducted by the World Health Organization, approximately 60% of individuals over 45 years old suffer from one or more chronic disease and it is expected that chronic conditions will account for 73% of deaths and 60% of disability by 2020, becoming the greatest challenge to be addressed by healthcare systems (Capelli, 2016, p. 28). These issues are especially relevant for developed countries, including the United States, and they could contribute to a significant increase in patient loads in family practice, which could adversely affect nurse-to-patient ratios and the quality of care available to patients and lead to a major increase in hospitalization and readmission rates. The presented information suggests that family nurse practitioners should focus on promoting of self-care in the clinical environment to address the needs of individuals with chronic health conditions more effectively and improve patient outcomes. Therefore, the implementation of Dorothea Orem’s Self-Care Model could allow achieving this important goal and ensuring the effective functioning of the healthcare system in the long-term.

Implementation Plan

Applying the model in practice would involve organizing educational classes on self-care for patients and their families. However, the key to introducing positive policy change in the clinical environment is establishing effective communication and productive collaboration between all involved parties. Therefore, the first step in implementing Dorothea Orem’s Self-Care Model in family practice would involve creating a clear vision statement illustrating the benefits of the innovation and sharing it with all involved stakeholders, including colleagues, patients, and the management by disseminating sufficient supporting evidence acquired through empirical research (Chun-Mei & Zhang, 2017). Specifically, it could be shared with the staff during group meetings in the form of presentations while patients could receive such information via e-mails, hospital website, and printed materials. Most importantly, it would be necessary to receive approval from the management. In order to achieve this goal, the management should be provided with sufficient data illustrating the financial long-term benefits of implementing the mentioned model in the clinical environment. Upon receiving the approval, it would be necessary to prepare education materials on self-care for different categories of patients and design comfortable schedules for patient admittance based on their feedback. The last step would involve informing patients and their families about the new program and its benefits and providing reminders on a regular basis.

Potential Barriers and Proposed Solutions

The most common barriers to implementing positive policy change in the healthcare environment include the fear of change among the staff and patients and toxic behaviors exercised by personnel. Specifically, the staff and patients could express significant concern about the efficiency of proposed innovations while the management could focus on evaluating the costs of their implementation. Additionally, some members of the staff could actively oppose the utilization of Dorothea Orem’s Self-Care Model in practice and resort to such toxic behaviors as passive hostility and team sabotage due to the desire to preserve personal authority and maintain familiar and conservative practices (Holloway & Kusy, 2014). The first issue could be addressed by explaining positive influence of self-care education on treatment efficiency, patient outcomes, and cost savings to all involved parties and establishing productive collaboration between them. However, overcoming toxic behaviors in the clinical environment would require utilizing crisis management. Specifically, it would be necessary to consolidate team efforts on persuading the opposition to accept the proposed change and act as a mediator between the sides to facilitate and hasten the process of finding mutually beneficial consensus (Edmonson, Sumagasay, Cueman, & Chappell, 2016).

Conclusion

To conclude, the lack of self-care knowledge and skills among patients negatively influences the effectiveness of treatment and patient outcomes and contributes to increasing hospitalization and readmission rates. This situation is especially relevant for family practice due to the overall aging of populations and the increasing number of patients with chronic health conditions who require constant care. Utilizing the principles of Dorothea Orem’s Self-Care model in the clinical environment could assist in promoting self-care among patients and addressing their needs more effectively. Therefore, it could be helpful to organize educational classes on self-care for patients and their families. The implementation process would involve creating a vision statement, supporting it with evidence-based data, disseminating information about the benefits of the proposed change to all involved parties, receiving approval from the management, preparing educational materials, and creating comfortable schedules for patient attendance. Potential obstacles to the introduction of this program could include the fear of change and toxic behaviors in the workplace. However, these issues could be addressed by establishing effective communication and productive collaboration between the staff, patients, and the management and using crisis leadership to find mutual understanding with the opposition.

Nowadays the problem of cultural care is particularly acute. Many nurses tend to polish professional caring skills ignoring the cultural competence in their daily activities, thus strengthening misunderstandings in the nurse-patient relationships. The purpose of the current research is to perform the concept analysis of the transcultural nursing theory developed by Madeleine Leininger. To conduct this investigation, the author used a deep and thorough literature review to study major concepts of the theory and investigated its reliability and applicability in different nursing settings and nursing-related fields. The findings have shown that there are different challenges nurses can face while working with the patients from diverse cultural backgrounds. Furthermore, it was discovered and analyzed that the transcultural concept is applicable to different settings and nursing researches. Leininger’s transcultural theory offers a unique approach to work with representatives of diverse folks. Moreover, the theory with its methods of data collection can serve as the helpful instrument while conducting a research into nursing.

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Concept Analysis of Leininger’s Nursing Theory

The most enduring problems related to nursing include clinical observation of poor quality and low integration of nursing theories into practice in terms of transcultural environment. It happens due to the lack of cultural competence. The majority of people do not think that cultural care is necessary for providing health care services. However, owing to different kinds of barriers, patients from different cultural backgrounds remain unsatisfied and misunderstood. Thus, the transcultural theory of nursing developed by Madeleine Leininger becomes widely spread due to its reliable approaches ensuring patients’ well-being regardless of their religion, beliefs, and value systems. An application of the theory in daily practices will reduce shortcomings in caring, improve understanding between nursing staff and various patients, and enhance the overall quality of health care. Regarding the necessity to promote cultural competence among young and experienced nursing personnel, it is important to determine what approaches would be applicable to a range of settings. Therefore, the paper focuses on the concept analysis of Madeleine Leininger’s transcultural theory and its application to nursing practice and other nursing-related fields.

Literature Review

Major Concepts

The cultural or transcultural concept of caring is based on the knowledge about individuals and groups from different cultural environments and their care in diverse institutions of health care systems. Leininger’s theory is distinctive because it is built on the socio-cultural and linguistic competence . In other words, one can define it as the use of culturally specific definitions and expressions related to health care. Another focus of the concept is people, nursing, and professional care systems. Such division into the categories is essential for practice because it contains the characteristics of each system along with specific requirements and guidance on care provision. Moreover, it allows to define similar and distinctive elements of cultural care or cultural care universality and diversity respectively . The aforementioned two definitions are decisive in daily nursing practices.

A number of health care institutions and nurses do not pay particular attention to cultural care. This position may have an excuse that people do not fundamentally differ in terms of their basic needs, so there is no necessity to develop or find specific approaches to caregiving. However, it is a gross misconception to overlook the importance of this factor. Since health care is linked to psychological, emotional, and mental basis in general, the interconnection of nurse’s and patient’s beliefs and values has to be established accordingly to provide holistic care and meet patients’ needs. Therefore, cultural care is associated with medical personnel’s understanding and recognition of cultural and religious divergence of a patient. In turn, it involves a continuous research of lifestyles and customs of different cultural communities to find a common language with patients and communicate with them respectfully. In view of this, cultural diversity means a response to multicultural characteristics of the patient population. Universality includes the expressions related to care existing in a particular culture and influence on the perception of care. For instance, different policies forming a national health care serve as an example of universality. Generally, principles of care diversity and universality make nurses consider and recognize the beliefs and cultural background of every patient and integrate them into a treatment plan to enhance curing.

This background is crucial for nurses who mainly work with representatives of different cultures. The setting that will be described in detail below analyzes an experience that is challenging and frustrating enough even for highly skilled professionals with rich nursing expertise (Amiri, Heydari, Dehghan-Nayeri, Vedadhir, & Kareshki, 2016). Hence, the theoretical knowledge should be applied not only when nurses work in foreign countries, for example, when they serve as volunteers of health care educational programs or interventions in the third-world countries. Amiri et al. (2016) define the migration as the first cause of cultural diversity in various societies. Therefore, it is no wonder that such conditions have a huge impact on health care systems. As it was mentioned earlier, Leininger’s transcultural theory is focused on minimization of the cultural barrier while delivering health care services and maximization of quality of the care.

Apart from the general notions, the transcultural theory of caregiving has its major concepts that are explicitly incorporated in the nursing practice. Some of them, such as care universality and diversity, were described above, but there is a range of other definitions that form a basic framework of cultural care. The major concepts include different notions essential in comprehensive understanding and building a practical framework in nursing and caregiving. Thus, transcultural nursing refers to a branch focusing on the comparative analysis of cultures and their characteristics as well as on their incorporation into a set of caring practices and values. It is aimed at provision of meaningful and effective nursing care services . Ethnonursing, in turn, studies nursing care practices, beliefs, and values as cognitively perceived by a certain culture through their value system, experience, and beliefs . The rest of major concepts reflect the understanding of nursing in terms of the diverse multicultural environment. As one can notice, working in this environment becomes a frequent experience for nurses; thus, an understanding of the main principles will minimize shortcomings in caring for the patients from different cultures.

Returning to the concept of culture care universality and diversity, it is worth mentioning that it was developed from observing pediatric patients from diverse cultural backgrounds and analyzing their response to health care specialists in a child psychology setting . Having observed the situation, Leininger noticed that children who have a multicultural background do not respond in the same way as children with the nurse’s background . Interestingly, those children responded negatively in comparison to the others. Therefore, it pushed the investigation and evolvement of the theory to a higher level because the same treatment plan for different patients cannot have the same positive outcomes and effective recovery. Much depends on communication between the patient and the caregiver, the ability of both to collaborate while accepting the treatment plan, and acknowledgment of patient’s values and beliefs that should be considered in the caring process.

Appropriate Settings

To prove the theory’s relevance, it is necessary to begin from its application to appropriate settings. Leininger’s transcultural concept can be reliable in various settings. During the literature review, three settings (i.e. patients with chronic diseases, diagnoses and treatment, genital and rectal problems) were chosen to observe how the transcultural theory can be applied to the specific issues. It is important to implement the major concepts into daily practices because each setting is unique and poses various challenges that should be prevented or overcome. For example, following the concept’s direction would help to minimize the communication barriers that are common for different settings in health care services delivery. Apparently, one type included language barriers as many patients used different languages or dialects completely unknown to health care workers. Logically, it is hard to understand a foreign language without learning it. Moreover, some explanations of health care procedures or activities are impossible both to be understood by a patient and to be given by a care provider. Additionally, the second type of the barriers is associated with diverse interpretation of disease symptoms and other signs used between personnel and patients. The representatives of different cultures confused health care staff with their perceptions and expressions of symptoms. Frequently, the patients could not explain what they felt due to their own understanding of a particular symptom or their embarrassment to give such information to the practitioners and nurses. In this case, the application of the theory should be focused on finding a common language all the way to hiring a translator, learning the language, etc. Establishing a contact between a patient and a nurse is one of the major principles of the transcultural theory that has to be applied.

Patients with chronic diseases setting. This setting is very important because the patients need constant examination and care to keep their health in a normal state. The reason for implementation of Leininger’s theory is irregular follow-ups revealed during the investigation. Due to this situation, immigrants were indicated as patients having more developed chronic diseases. Again, one of the reasons for that is misinterpretation of information and general misunderstanding because of the cases mentioned above. Another reason belongs to the inability of many immigrants to afford comprehensive treatment. Iranian health care services are highly expensive for immigrants, especially, when they live in severe poverty and have no insurance respectively. Moreover, the legal conditions in Iran require the residential permit for immigrants; thus, non-registered people have no right to visit the public clinics or hospitals even in emergency cases. Therefore, it makes sense to make a request to the government, asking to make health care services more accessible for the patients. Even the theory in question suggests that everyone deserves high-quality care that has to be affordable. The situation becomes worse when many immigrants themselves are careless about their health. Notably, many of them ignore the health problems until they are accidentally found. Such circumstances underline the necessity to find approaches not only to care but to educational activities for the population. People should know what to do in some cases and how not to be afraid to ask health care providers for help and guidance.

Diagnosis and treatment setting. Diagnosis and treatment are core activities ensuring the patient’s recovery and well-being. The application of the transcultural concept in this setting is caused by mistrust to healthcare personnel. The lack of trust was expressed in different ways but the most common ones were related to a range of beliefs or behaviors. A significant number of immigrants believe that when a doctor prescribes more drugs, he or she has diagnosed an illness better; others frequently change their practitioner or nurse and ignore recommendations of experts. Amiri et al. (2016) noticed that many low-educated patients were sure that injections are more effective than pills or other medicines, so they asked to be injected very often. The problem deteriorates with immigrant’s sharp rejection of trainings or educational meetings and talks due to their general mistrust to health care professionals and better trust to neighbors or friends. It is obvious that this serious cultural issue requires that some possible alternative approaches to manage those patients are found. Their beliefs and opinions grounded mainly on illiteracy and a strong feeling of belonging to their traditions are more powerful than it may seem, which significantly hinders health care practices. However, one can notice that the lack of proper communication skills is evidenced. Therefore, the application of the theory should be based on finding the methods to influence the patients and their beliefs and make them want to know about their health. Theoretically, health care providers must become patients’ friends . Therefore, it is essential to promote cultural competence in order to enforce the efforts of the personnel to find the ways to communicate with the patients.

Genital and rectal problems setting. This setting is the most challenging among others because it relates to the problems that people are embarrassed to discuss. Quite often, immigrants’ cultural-personal traits do not allow them to talk about such sensitive matters. Therefore, implementation of the transcultural theory is crucial for this kind of setting because when a patient has a problem, he or she has no need to be afraid to discuss it with an expert. For instance, being shy to tell the professionals about some health concerns was much impeding to an appropriate care provision. It was especially common for genital and rectal problems. Amiri et al. (2016) emphasized that women expressed shyness more while discussing their health state; however, such tendencies were also indicated in men. For instance, religious beliefs in Iran restricted females to be examined by males. Hence, the patriarchal principles determined men’s decisions about treatment of women. Apparently, the cultural peculiarities make some interventions or surgeries in genitals impossible, even if an illness poses a serious threat to further well-being or even life of a person. Furthermore, most immigrants have poor communication skills and are isolated from others. Undoubtedly, it does not help to establish a common language and harms their health, not to mention misunderstandings with health care experts. Again, the problem lies in a poor communication. It is the staff that bears the responsibility for patient’s well-being, which presupposes that a medical worker must find the ways to understand a patient.

Application of the Theory in Future Practice

If the world becomes more globalized every day, this will influence each sphere of life, and nursing care and health system is not an exception. The example of Tollab area in Mashhad described earlier has shown that multiculturalism poses a range of barriers and discordances in caregiving both for patients and nurses. Therefore, the ultimate goal for the health care system and my future experience should be a minimization and avoidance of such discrepancies in the future practice . The recognition of possible barriers and finding culturally and linguistically applicable methods will contribute much to the improvement of the situation.

Working in a multicultural environment is highly interesting and can be well-paid, but it is a good career option only if the care provided complies with the standards and one’s cultural competence. Leininger’s cultural care diversity and universality represent a well-structured approach to a culturally congruent care promotion . Therefore, the basic principle of my future practice is avoidance of expressing my own beliefs to a patient. I would prefer to fit myself to the patient’s requirements to understand him or her, learn the basic expressions of states, and gain trust. Thus, it is a matter of the utmost importance to pay special attention to self-development in terms of cultural competence.

Not surprisingly, every cultural group practices own original folk healing procedures based on their beliefs or traditions. There is no need to implement those procedures into the future practice; however, it is essential to bridge them to create a basis for culturally congruent care. Therefore, before delivering health care services, I would conduct a research to gain enough knowledge and be aware of beliefs, practices, and expressions of some people for my further professional development . In particular, it is essential to determine what attitudes, phrases, expressions, and other issues pertaining privacy, illnesses, dietary, health, death and grief, and other emotional and physiological states are acceptable for a particular cultural community.

Additionally, employment of the three modes of action in the future practice enforces critical thinking and judgment regarding making diagnoses, treatment plans, implementations, interventions, and other activities in terms of cultural congruency that is helpful for the advancement of professional skills. One of the first modes of nursing practice to be applied is a revision of diagnoses with a purpose to make them culturally acceptable and sensitive for diverse patient communities (Leininger & McFarland, 2013; Wayne, 2014; Sagar, 2012). In other words, I should rely on maintenance and preservation approach implying that generic ways of treatment or another component of care would be more advantageous than the professionally accustomed one. As it was discussed earlier, communication between a nurse and a patient is a prerequisite for an appropriate way to caregiving and recovering. Thus, I have to employ accommodation and negotiation modes offered by Leininger when interventions including adaptation should be negotiated with patients personally or within groups. Additionally, I would promote culturally congruent care through education of patients related to preventing or coping with diseases, recovering from someone’s death, or development of healthy habits . For instance, when a patient has high blood pressure, he or she can be informed that garlic can soften this symptom, though it does not deny the prescribed intake of medications. The third mode, i.e. restructuring and repatterning employment in my daily practices will refer to making decisions together with a patient, which can be related to modification or changes of the treatment plan or other caring issues to improve the health outcomes. The transcultural nursing theory becomes more popular and important in terms of its application in future practices and will help many professionals to enhance their nursing career.

Application in Nursing-Related Fields

Leininger’s transcultural theory is applicable to conducting a nursing research. For example, the method of ethnonursing makes a significant contribution to the whole body of the concept and knowledge of nursing. The cultural theory encourages the participatory method in the process of the research. Notably, Madeleine Leininger developed the principles, so-called enablers, referred to the stranger-friend relation and observation-participation-reflection. It would be essential in the situations described by Amiri et al. in Mashhad, Iran (2016), despite their primary connection to the research rather than to the nursing practice. However, the ethnonursing approach encompasses moving from being a stranger to a friend that is helpful in collecting meaningful and accurate information . Fundamentally, the model with enablers is suitable for any research conducted in different settings. The application of the ethnonursing method in an investigation promises a possibility to meet a range of criteria such as credibility, context consideration, confirmability, and many other factors that are linked to the qualitative research.

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Conclusion

The analysis has shown that foremost healthcare providers should be the best not only in making a diagnosis and providing treatment but also in leading experts in the area of cultural sensitivity. Every patient deserves the most effective medical care independently of his or her cultural background, religion, values, perceptions, and beliefs. Moreover, these people should be treated by the nurses who respect and consider the needs of their patients. Therefore, in the circumstances of rapidly developing world globalization, the transcultural nursing theory suggested by Madeleine Leininger becomes one of the leading paradigms for care provision to patients from different cultures. The core principle of the concept is to combine nursing care with the cultural approach. Sometimes, it poses a challenge for both inexperienced and skilled nurses; however, Leininger’s theoretical framework helps to find answers to these questions. The observation of different settings helped to determine and fully understand that finding approaches is simple theoretically but is rather problematic in a real practice. Thus, the incorporation of culturally congruent care into daily practice plays a crucial role in the professional development of a care provider.

Study on Oxidative Stress in Type 2 Diabetes Subjects

Conditions

In the line of capturing an accurately assessing the effects of yoga in reducing stress level among the elderly type 2 diabetes patients, the research has first evaluated the oxidative stress levels among the young and elderly. It was necessary for identifying the impact of the three-month yoga exercises on the oxidative stress. The study applied a sample of (age>60=42) and (age<60, n=45) that was subjected to the yoga while still continuing their medication (Shreelaxmi et al., 2016). Moreover, the study ensured that the participants were non-alcoholic and non-smokers and the fact that all were in good health for the previous 30 days. There was also a condition for the participants to be willing to attend yoga classes. These conditions were necessary to ensure that the changes that were exhibited by the participants after the research experiment were mainly due to the effects of the yoga exercises.

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Measurements

During three months of participation in yoga classes, the patients were subjected to length measurements, weight measurement, blood pressure, and BMI. There was also the analysis of plasma, aimed at capturing the levels of glucose and vitamin C. Packed cell and red blood cells hemolysates were analyzed in order to capture the element of malondialdehyde (MDA) and the trend exhibited by glutathione levels.

Results

Yoga attendance rates amounted to 90-95%  with 82 participants, who completed the study. Age and MDA had a positive relationship (+0.274) while the relationship between age and antioxidant levels of GSH (r-0.077) showed negative results, and there was a similar case with vitamin C (r-0.083). Another variable that was of interest showed the correlation between Malondialdehyde and antioxidants, and it has also displayed a negative relationship of GSH (r-0.186) and vitamin C (r-0.012) (Shreelaxmi et al., 2016). Moreover, the two groups demonstrated a decline in the mean BMI: group 1 (younger participants= p<0.001) and in group 2 (elder participants=p<0.001). There was also a positive change in oxidative stress that was indicated by MDA, because there was a reduction of 18% and 22% in group 1 and 2 respectively. Glutathione levels among the two groups have also improved with group 1 capturing a 15% growth, while in group 2 there was a relatively small increase of 10% (Shreelaxmi et al., 2016). Generally, it was clear that yoga played a helpful role when it came to the reduction of the blood pressure.

Analysis of the Results

The results clearly indicated that exposing elderly to yoga for three-month plays a crucial role in reducing the oxidative stress of patients who have diabetes type 2. Moreover, the study made it evident that oxidative stress increases with age among those who have diabetes type 2. It means that older adults with this disease are more vulnerable to oxidative stress. The study also shows that oxidative stress makes diabetes type 2 more complicated, and this aspect exposes the older adults to more risks (Vora & Evans, 2012). Moreover, it is clear that the yoga’s impact on reducing oxidative stress was higher comparing to the younger group. Moreover, thorough yoga exercises also helped in reducing the BMI that was demanded by caregivers of people suffering from any form of diabetes. It was also the case when it came to reducing the blood pressure.

Relevance of the Findings to Diabetes Management and Nurse Practice

In the management of diabetes nurses and other physicians need to ensure that patients can keep their blood pressure under control. Moreover, there is a need to encourage patients to physical activity, necessary for keeping the BMI on the check (Felig, 2016). Another key demand is to protect patients from any form of stress, since it may lead to the body producing hormones that may interfere with the effectiveness of insulin. All these demands are supported by the results of the study, which indicates that yoga can provide a platform upon which management of the diabetes type 2 among the elderly people can be done in a more proactive manner. The application of yoga brings benefits, as it makes the management of diabetes type 2 among the elderly more engaging and exciting. Moreover, through the reduction of the oxidative stress that just like any other type of stress leads to complication among the diabetes patients (Shreelaxmi et al., 2016), yoga exercises can be used not only to reduce stress levels among the elderly but also to help them to be active. It influences the management of cases of diabetes type 2 among the elderly, as it becomes less complicated and does not depend exclusively on medication when dealing with cases such as blood pressure.

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Conclusion

It is evident that yoga exercises provide means for reducing the oxidative stress among the elderly. Moreover, any form of stress makes the treatment of diabetes more difficult, since it reduces the effectiveness of insulin in the body, as it leads to the production of hormones. In this context, the study clearly demonstrates that yoga can also help in reducing blood pressure that is necessary when it comes to managing cases of diabetes. It is clear that caregivers can recommend that their elderly patients with diabetes type 2 attend yoga cases in order to reduce their oxidative stress levels and manage their blood pressure levels while at the same time be active.  

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Prevalence of PKU

Phenylketonuria is common in Caucasians. The prevalence of phenylketonuria in the United States appears at one case in every 10,000-15,000 new births. The incidence of the disease varies depending on different populations, geographic locations, and ethnic groups. According to Hardelid et al. (2008), the prevalence of the condition in Chinese, Korean, and European societies stands at one case per every 10,000 live births. Phenylketonuria is less prevalent in people of South Asian and Sub-Saharan descent, which indicates the variation in the rate of occurrence. In Turkey, however, the prevalence is relatively higher with one case of phenylketonuria occurring in every 6,500 live births (Dobrowolski et al., 2011).  

The frequency of the disease is relatively higher among cultures that engage in consanguinity as noted in the case of Saudi Arabia, Turkey, and Gaza, which have a prevalence of one case in every 3500-6500 live births (Dobrowolski et al., 2011). Nonetheless, some countries record relatively lower incidence rates as in the case of Finland whose prevalence is one case in every 100,000 live births (Dobrowolski et al., 2011). On the contrary, the prevalence in Latin American is found in one case per every 25,000-50,000 live births while Thailand records less than one case in every 200,000 live births (Blau, van Spronsen, & Levy, 2010). The frequency, however, is extremely low in African countries when compared to other regions. In some countries, the incidence of certain forms of the disease is very high. For instance, the prevalence of the classic form of the genetic condition is very high in Turkey at 47 percent, which is opposite to Spain given that this state records a higher incidence of mild hyperphenylalaninaemia. Evidently, geographic biases exist as far as the incidence of phenylketonuria is concerned considering that different countries and regions have distinctive prevalence rates.

PAH Gene

Genetic mutations or variations in the PAH gene lead to the development of PKU. The PAH gene is responsible for giving instructions for the production of phenylalanine hydroxylase, which assists in the processing of phenylalanine to form tyrosine and other important compounds (Schlegel, Scholz, Ullrich, Santer, & Rune, 2016). The resulting compound tyrosine participates in the composition of various important hormones and other chemicals necessary for neurotransmission. It is also fundamental in the production of melanin, which explains the faint skin and hair color in people with PKU.

Blau (2016) notes that over 950 mutations in the PAH gene may be explained by the development of PKU. The mutations alter single amino acids involved in the formation of phenylalanine hydroxylase. In most cases, mutations involve the replacement of arginine with another amino acid, preferably tryptophan. However, PAH mutations might occur due to the removal of small quantities of genetic material from the PAH gene. The gene is also regarded as Phenylalanine 4-Hydroxylase, phenylalaninase, or PKU1 (Genetics Home Reference, 2016).

Inheritance Pattern for PKU

Normally, the disease exhibits an autosomal recessive pattern in which the two copies of the phenylalanine hydroxylase (PAH) gene in each cell exhibit mutations or variations in their genetic composition (Genetics Home Reference, 2016). The mother and the father of a person with this condition have a copy of the variant gene. Unlike their child, the parents have no visible signs and symptoms connected to this autosomal recessive condition. The absence of signs and symptoms of the disease in parents who carry the mutant gene indicates that they have a normal gene. The mutations result in a defective production of phenylalanine hydroxylase, an important enzyme that is responsible for phenylalanine metabolism (Genetics Home Reference, 2016).

Disease Process for PKU

When each of the parents has a copy of the mutant PAH gene, the resulting child suffers from phenylketonuria (Genetics Home Reference, 2016). Despite this fact, the signs and symptoms take a few months to appear in infants with the autosomal recessive disorder. The gene mutation undermines the production and functioning of phenylalanine hydroxylase. The body cannot adequately process this amino acid, which causes a significant increase in phenylalanine in a person’s blood, including other body tissues (Genetics Home Reference, 2016). Brain damage frequently occurs because of the sensitivity of the nerve cells found in the brain to relatively high phenylalanine levels.

 Classic phenylketonuria usually manifests itself when there is little or no phenylalanine hydroxylase activity in the body. Consequently, there is a buildup of phenylalanine to levels that have devastating effects on the brain, namely to the point of inducing severe brain damage. Further, classic phenylketonuria is linked with other serious medical conditions, which often occur because of excess phenylalanine in the blood and body tissues. Variant PKU and non-PKU hyperphenylalaninemia have milder signs and symptoms, because the gene mutation in these cases is less severe and allows a certain degree of phenylalanine hydroxylase activity (Genetics Home Reference, 2016).

PKU Case Study

According to this case study, the daughter aged 5 tested positive for PKU at birth, which indicates that the Turkish female and the husband have a copy of the mutant PAH gene. The parents of this child are carriers of these abnormal genes. When the gene copies interact, they produce two carriers: a non-carrier and a PKU positive child based on the autosomal recessive pattern. Therefore, there is 25 percent likelihood that parents with the mutated gene will have a child that is PKU positive (Marble, n.d.). The daughter tested positive for PKU, since the copies from the carrier parents came together as a result of the autosomal inheritance pattern. The two sons, however, may both pass as carriers, or one may be a non-carrier depending on the interactions of the mutant genes.

Regarding the family history of the Turkish female, the inheritance pattern indicates a rather unusual case. One of her siblings tested positive for PKU, but the positive case occurred in the fifth child who is aged 22. It demonstrates that there is a chance that odds could change, especially taking into account that there is a greater likelihood that a child will become a carrier rather than testing positive for PKU. As already noted, all the children have at least one mutant PAH gene, but PKU only occurs in children who inherit two copies of this gene from their parent (Genetics Home Reference, 2016). Of the four siblings, the brother aged 26 has three children, but one died as a result of a brain hemorrhage. The deceased may have been PKU positive considering the inheritance pattern of this condition.

In addition to this, PKU is associated with a brain damage and can even lead to serious medical problems when treatment is not promptly provided, already starting at a tender age. Even in such a way, the brain hemorrhage might have occurred because of a different problem, especially if the mother of these children is not a PKU carrier or does not have the defective PAH gene. Speaking of the autosomal recessive pattern, each of the siblings has the altered PAH gene, which implies that marrying a partner with a copy of this gene will lead to at least one child testing positive for PKU (Genetics Home Reference, 2016). The father and mother of the Turkish female also carry the mutant gene based on the inheritance pattern shown in the family history. It displays an autosomal recessive pattern given that only one of the five children tested positive for PKU. It is acknowledged that one in four children might have PKU when both parents have altered genes (Marble, n.d.). It suggests that there is a high risk of developing PKU in at least one child among the four.

Treatment Recommendations for PKU

Blau, van Spronsen, and Levy (2010) note that phenylketonuria is one of the genetic conditions that is considered as treatable, which implies that the person suffering from this conditions enjoys a fulfilling life. The treatment for PKU involves having a low-phenylalanine diet that starts from infancy to avoid the accumulation of the amino acid in the blood and tissues (Verduci et al., 2016). It is important to adhere strictly to this kind of diet in order to maintain phenylalanine at a minimum level and reduce the adverse effects of excessive phenylalanine. The maintenance of the low- phenylalanine level guarantees normal mental and cognitive growth. Treatment also involves the use of supplements, low-protein foods, grains, and phenylalanine-free formulas for infants (Verduci et al., 2016).

It is recommended for people with PKU to follow the low-phenylalanine diet throughout their lives for optimal mental function and reduced incidence of behavioral problems. On the one hand, people with classic PKU have to adhere strictly to their diet because their bodies can accumulate large amounts of phenylalanine as a result of the severely low phenylalanine hydroxylase activity. On the other hand, people with milder forms of the condition can sometimes deviate from the low phenylalanine diets with little consequences (Verduci et al., 2016). It is possible because their bodies have relatively high phenylalanine hydroxylase activity that can process the amino acids to produce tyrosine.

 People with this condition should avoid high protein foods and commodities with artificial sweeteners such as aspartame and saccharin, because they have relatively high quantities of phenylalanine. One can easily make adjustments to the diet depending on phenylalanine levels in the body. A health care professional can add or remove diet components depending on the monitoring results. For infants, there is a gradual addition of low-phenylalanine foods into the diet apart from the special formula to facilitate normal neurological and body growth.

In the case of the 5-year-old child in the case study, it is appropriate to determine whether she is suffering classic PKU, variant PKU, or non-PKU hyperphenylalaninemia. The knowledge about the form of PKU can assist in defining dietary requirements and adjustments over the course of time. The child will require a low- phenylalanine diet, where in case of failure to adhere to it, she can suffer from both behavior-related disorders and mental retardation due to the poor neurological and cognitive development.

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Consequences of Non-Adherence to the PKU Diet

In case she continues to eat a normal diet instead of the low-phenylalanine diet, there is a higher risk that she will experience developmental delay, seizures, or even autism in the course of her life. Brain damage may also occur, provided she is suffering classic PKU, because phenylalanine will accumulate in the blood and body tissues and act as a toxin against brain nerve cells. In case the PKU positive daughter has the mild form of the disease, fewer health problems will arise even with a special diet as the body can still process a small amount of phenylalanine in the diet. Mild PKU will lead to less severe brain damage, and mild hyperphenylalaninemia will not attract any health problems in the absence of a special diet, which is frequently regarded as an important and effective treatment mechanism (Verduci et al., 2016).

Nonadherence to low-phenylalanine can also interfere with school functioning and even trigger mental disability in the first years in a person with the condition. More specifically, attention-deficit hyperactivity disorder (ADHD) is a common condition associated with nonadherence to low-phenylalanine diet. Pregnant women who fail to adhere to the proper nutrition, increase chances of the child developing a small head, suffering from mental retardation, seizures, and even intellectual disability (Ward, Hisley, & Kennedy, 2015). It can also result in fetal growth failure and congenital disabilities. Therefore, it is appropriate for women with PKU who seek to undergo dietary adjustments and monitoring to ensure their bodies have acceptable levels of phenylalanine. In addition, the women should adhere to low-phenylalanine diets throughout the course of their pregnancy to prevent the problems interrelated with nonadherence to specific diets (Marble, n.d.).

PKU Counseling

The parents should understand that each pregnancy means that there is a 25 percent risk that the child will bear two copies of the mutant gene that cause PKU (Plomin, DeFries, Knopik, & Neiderheiser, 2013). There is also a 25 percent possibility that the child that they bear is a non-carrier, and thus a normal child with no risk of getting a PKU positive child in the future according to the status of the spouse. Moreover, there is a 50 percent likelihood that the next child is an unaffected carrier of the altered gene copy (Plomin, DeFries, Knopik, & Neiderheiser, 2013). The other important areas of counseling involve the diet of the PKU positive child.

I would advise the parents to maintain a low-phenylalanine diet to ensure that a child enjoys a normal and fulfilling life with no episodes of behavioral problems, mental disability, or even brain damage. I would refer the parents to genetic counselors and geneticists, because these can provide genetic counseling services, including additional information on dietary management for the PKU positive daughter. I would also send the parents to a nurse practitioner, a registered dietitian, a social worker, and a pediatrician, for the fact that these health care professionals have to work together with the genetic counselor for effective management of the dietary and care-related needs of the PKU positive child.

Application of the Knowledge Gleaned in Clinical Practice

The information gleaned from the PKU case study is important in nursing practice, since understanding the condition, inheritance pattern, signs and symptoms can help a nurse practitioner provide accurate information. A nurse practitioner can understand who to refer the patient to for counseling on the genetic condition and even assist in developing an effective dietary management plan for such a patient, depending on age and monitoring outcomes. As an important part of the team, a nurse practitioner may prescribe a special formula or foods for a PKU positive child.

Conclusion

Phenylketonuria is a genetic condition that follows an autosomal recessive inheritance pattern. The incidence of PKU changes across geographical locations and appears more prevalent in regions that practice consanguinity. There are clear geographical biases in the prevalence of the genetic condition with very few cases occurring in Africa and Asia. For PKU positive patients, it is important to adhere to low-phenylalanine diet to keep the levels as low as possible. Nonadherence can have devastating effects on the health of the patients and can induce congenital disabilities in pregnant mothers. Parents who plan to have another child should seek genetic counseling services from genetic counselors and geneticists. Parents should also find additional assistance from a team comprising a pediatrician, a nurse practitioner, a registered dietitian, a social worker, and a genetic counselor.

Male and female urinary incontinence is a severe health problem that impacts the quality of life among many people in the society. The incontinence affects people of all ages, cultural and socioeconomic backgrounds (Higa, Lopes, & D’Ancona, 2013). This health problem bears an enormous socioeconomic burden to the community. Urinary incompetence has an adverse impact on the health of the affected population because it reduces their quality of life, contributes to the occurrence of depression, increases hospital admissions and falls (Wood & Anger, 2014). The risk of admission among men with urinary incontinence is 3.2 and among women is 2.0 (Wood & Anger, 2014). Men with this condition are more likely to report increased risk of institutionalization and lower quality of life than men without this type of incontinence (Clemens, 2016). The same thing happens in women. In the United States of America, the annual cost of urinary incontinence is more than $32bn,  the cost for women over 65 years of age is twice those for under the age of 65 (Wood & Anger, 2014). For men the cost of this condition is lower compared to women because of the high prevalence of the disease in women (Wood & Anger, 2014). The purpose of this essay is to discuss the prevalence of urinary incontinence in males and females, its risk, and etiological factors.

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Prevalence of Male and Female Urinary Incontinence

The prevalence of this condition is higher in females than in males. It affects more than 200 million people in the world with more than 55% being women (Wood & Anger, 2014). However, the women proportion is an underestimate because over 50% of this gender may fail to report the presence of urinary incontinence to their professional health provider (Wood & Anger, 2014). Some of the reasons that may hinder effective reporting and seek professional help are the lack of knowledge about the current treatment options, stigma, and the belief that the contention is a normal occurrence in elderly populations. These allegations can be justified by the small proportion of males with the disease. According to Irwin, Kopp, Agatep, Milsom, and Abrams (2011), urinary incontinence affects more than 43 million men. Kuchel and DuBeau (2009) reiterate that male prevalence rates for this disease are about one-third that of women, but the gap in the ninth decade of life equalizes. Therefore, the prevalence increases with age in females suffering more than their male counterparts, although by the age of 90, the prevalence is the same for both genders.

Although the prevalence varies between the two genders, age has an enormous impact equally. Markland, Goode, Redden, Borrud, and Burgio (2010) found that the prevalence of moderate to severe urinary incontinence in 20 to 34-year-old men is 0.7% and 16.0% in men at least 75 years of age. Similar findings are reported by Shamliyan, Wyman, Ping, Wilt, and Kane (2009) who found that urinary incontinence affects 11% of males aged 60-64 years, but the prevalence increases to 31% in older men. In females the trend in prevalence is similar to that of men. Women aged 20 to 39 years have a prevalence rate of 7-37% for urinary incontinence while that of 60 years old and over is 9-39% (Buckley & Lapitan, 2010). Therefore, with the age, the risk of developing this health problem increases.

Etiological and Risk Factors for Male and Female Urinary Incontinence

The risk and etiological factors for urinary incontinence may differ depending on the gender of a person, although both o genders have some common risks. Recurrent urinary infections, advancing age, and high body mass index increase the risk of this health problem among both genders (Wood & Anger, 2014). Obesity and advancing age are known to increase the risk of developing stress urinary incontinence. Furthermore, individuals with a family history of the disease or its modifiable risk factors like obesity are more likely to develop the health problem. Smoking also increases the risk of urgency urinary incontinence, similar to high caffeine intake that increases the risk by 40% (Wood & Anger, 2014). Other risk factors include urinary bladder obstruction and neurological diseases (Higa, Lopes, & D’Ancona, 2013). Injuries to the spinal cord can also interfere with the nervous functions in controlling the bladder to cause incontinence.

Gender-specific risk factors are concerned with the anatomical and physiological variations between the two genders. In males, prostate cancer and its treatment through surgical interventions are the main risk factors for urinary incontinence (Higa, Lopes, & D’Ancona, 2013). Pregnancy and childbirth are risk factors of stress urinary incontinence, vaginal delivery is worse compared to caesarean delivery, since the risk of urinary incontinence in nulliparous women is10.1% compared to 15.9% and 21% of those who give birth through caesarean and vaginal delivery respectively (Wood & Anger, 2014). Furthermore, hysterectomy increases the risk of incontinence because of its side effects including damage to pelvic floor muscles among others (Wood & Anger, 2014). Stress urinary incontinence also occurs due to vaginal prolapse, cystocele, and rectocele, which are common after hysterectomy.

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Conclusion

Male and female urinary incontinence affects many people around the globe by lowering their quality of life and increasing the expenditure on its treatment. It impacts women the most, although age determines its prevalence in populations. Advancing age increases the risk of the disease with the aged reporting high prevalence rates that the young ones across both genders. Other non-gender-specific risk factors include smoking, injuries to the spinal cord, urinary tract infections, neurological diseases, and so forth. Prostate cancer and its treatment through surgical interventions increase the risk among males. For women, childbirth, pregnancy, and hysterectomy are the major risk factors.

Generalized anxiety disorder (GAD) is a mental condition that makes a person worry too much. This condition can be diagnosed when the patient is seen to be exhibiting some symptoms as highlighted in DSM-V. Treatments for GAD include medication and psychotherapy sessions. Children and adolescents are normally affected by the condition the most due to their developing personality and young brains. Therefore, they need maximum support from family members during intervention in order to cope or overcome this situation.

Keywords: generalized anxiety disorder, disorder diagnostics, psychiatric treatment

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Generalized anxiety disorder (GAD) can be described as an excessive fear that is not caused by any specific event or problem. This kind of fear is commonly associated with persistent worry that is considered unrealistic (Friedman et al., 2011). GAD is common in children and normally becomes more severe as they grow up. More often than not, as the afflicted children start attending school and participating in various activities, such as sports or academic work, alongside their peers, the worry intensifies and makes their situations worse. Children with GAD tend to have a lot of factors influence their fears. Research has proved that they are more worried about many things as opposed to other children who do not have the disorder (American Psychiatric Association, 2013). The excessive and unrealistic worry for children and adolescents is often associated with increased concerns over the patients’ own safety and security, persistent worry over the security of their loved ones, including their parents and siblings, fear of failure at school or nonperformance in sporting activities, and fear of attack or occurrence of a catastrophe such a natural disaster.

All the listed precipitating factors for fear may change at one point, however, the patients are unlikely to be able to control these worries. This means the anxiety tends to persist with time. GAD affects children and adolescents because it interferes with the mental capability of these young people. Children and adolescents, in particular, have young brains that are still developing, and their minds are expected to process and learn new information. This, however, is not the case with the young people affected by GAD (Friedman et al., 2011).  Since these children are unable to control the problem of excessive worrying, they cannot process information. They also lack concentration and, therefore, are unable to take part in many crucial activities that they should be involved in at their age (American Psychiatric Association, 2013).

Children with this disorder normally tend to seek reassurance of their security due to safety-related worries, which is likely to interfere with their personal growth and eventually their social relationships as they grow into adolescence. There is also a tendency by most of those who are affected by GAD to be perfectionists, excessively conforming, and extremely self-critical. This is made evident by the tendency to perform even insignificant activities several times to ensure that they are perfectly done (Friedman et al., 2011). The GAD patients normally do this due to the fear of failing or disappointing their parents, which is one of the worries associated with GAD. This paper explores the prevalence, diagnosis, treatment, and recovery options for adolescents and children, as well as the role family support plays in the recovery from GAD.

Prevalence

GAD is common in children and adolescents. The prevalence among them is high, and the impact of the condition is likely to persist into adulthood. Statistics show that about 3.1% of the U.S. Citizens or 6.8 million people are affected by GAD. Further, it affects more females than males both in childhood as well as in adulthood. Some of the factors that precipitate GAD include extraordinary occurrences such as natural disasters. Young people are more at risk of being diagnosed with the disorder.

Diagnostic Criteria for Generalized Anxiety Disorder

GAD affects children, adolescents, and adults. Whenever one suspect that they have the condition, it is important to immediately seek help from an expert. According to American Psychiatric Association (2013) the criteria for GAD diagnosis based to DSM-V are as follows:

1. Excessive worry and anxiety lasting more than six months (can be associated with school-related activities).
2. Inability or difficulty to control the anxiety.
3. Children and adolescents must exhibit at least one of the following symptoms: restlessness, irritability, getting easily fatigued, difficulty in sleeping, difficulty in concentrating (mind going blank), and muscle tension (American Psychiatric Association, 2013).
4. The symptoms cause distress or impairment of social functioning.
5. The anxiety is not caused by consumption of drugs or other substances and is not associated with another illness (i.e. hyperthyroidism).
6. Anxiety is not linked to another mental disorder.

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Common co-occurring disorders

Depression is a common disorder associated with GAD.  The excessive worries can lead to high levels of depression as one engages more in worrying about the future, safety, and other issues related to their lives. Depression can push children affected by GAD to distrust other people and internalize their problems. One of the common ways of doing so is through withdrawal from age-appropriate activities that are performed by their peers (Friedman et al., 2011b).  This means that such a child lacks a normal childhood. The withdrawal in many cases manifests through truancy whereby children affected by the disorder miss school. GAD is also associated with drug and substance abuse, which typically occur through self-medication.

Social anxiety disorder (SAD) is also likely to occur alongside GAD. For children and adolescents, SAD tends to occur especially in the situations that the worry is related to and in places where social interactions are required such as school. If the patients feel that they have not done enough to feel appreciated despite their effort to do things perfectly, they may move into social isolation due to the fear of being ridiculed or laughed at by peers (Friedman et al., 2011b).

Post-traumatic stress disorder (PTSD) is likely to occur in children and adolescents in the even that their worry comes from an occurrence that threatened their safety or the safety of their loved ones. Such events may include natural disasters or accidents. PTSD may aggravate GAD if the patient associates specific events with the general fear that he or she has and, thus, make the condition more complex (Friedman et al., 2011a).

Treatment for General Anxiety Disorder

Psychotherapy

Psychotherapy is one of the most common treatment methods for GAD. Different categories of professionals can perform psychotherapy through what is typically known as “talk therapies” (Weisz & Kazdin, 2010). Some of the most commonly used therapeutic approaches include cognitive behavioral therapy (CBT), acceptance commitment therapy (ACT), psychodynamic psychotherapy, and interpersonal psychotherapy.

Cognitive behavioral therapy. CBT is critical in treatment of anxiety disorders, including eating disorders and mood swings. CBT is focused on dealing with feelings, emotions, thoughts, and behaviors. CBT is a short-term treatment that is frequently aimed at ensuring that the patient learns how to have personal therapy. In as much as CBT treatment tends to work towards ensuring individual therapy for patients, there are frequent cases of refresher treatment. CBT is usually present-focused, i.e. it deals with the current issues affecting the patient (Friedman et al., 2011b).

Acceptance commitment therapy. Just like the name suggests, ACT is about the patients accepting their situation by gaining more insight into their thinking and committing to improving the situation (Friedman et al., 2011a). The major focus of this kind of therapy is not to struggle to change the situation but rather to help the patient get more involved in meaningful and beneficial activities (Weisz & Kazdin, 2010). These activities help the patients solve the problems that they are involved in by dealing with the situation in more creative ways.

Psychodynamic psychotherapy. This kind of therapy is based on the belief or thought that in many cases, things that people are not conscious of can lead to inner conflicts that eventually results in anxiety and worries that affect the person’s mood. This kind of therapy is a long-term option, and it has helped the affected people to deal with anxiety in many ways (Friedman et al., 2011b).

Interpersonal psychotherapy. It was initially meant to deal with depression. The major belief in this form of therapy is that worries normally emanate from problems in interpersonal relationships, and, therefore, dealing with these interpersonal challenges is likely to help in reducing the GAD symptoms. Some of the skills acquired during interpersonal psychotherapy sessions include communication skills which can help children and adolescents improve their relationships with others and, hence, overcome the problems of anxiety (Reinholt & Krogh, 2014).

Medication

Antidepressants. They are considered among the most tolerated and accepted forms of medication, because they are accepted by most individuals. Antidepressants are not only meant for the treatment of depression but rather have the capacity to treat GAD and other anxiety disorders. Examples of antidepressants include SSRIs and SNRIs (Friedman et al., 2011a; Weisz & Kazdin, 2010).

Anxiolytics. Another group of medications used for the GAD treatment is anxiolytics, sometimes referred to as anti-anxiety medicines. Examples if anxiolytics include azipirones, buspirone, and benzodiazepines, such as alprazolam, clonazepam, and lorazepam (Weisz & Kazdin, 2010). Most of the medication in this category is normally preferred for short-term use, since they are habit forming and are in many cases the most effective within short time. In some instances, these medicines are used for symptom relief. A combination of psychotherapy and medication is always considered to be important in dealing with problems emanating from GAD, and in the long term, a combination of both methods can help in dealing with this problem permanently (Reinholt & Krogh, 2014).

How to Use the Intervention in Both Child and Family Sessions

Since GAD has more impact on children and adolescents, it is important to emphasize the treatment administered to patients in family sessions as well as on individual level. As evident from the preceding facts, this condition interferes with a person’s confidence in their abilities to perform and succeed. Consequently, patients, especially children, require reassurances, which means that the therapy sessions must be done with support from close family members (Reinholt & Krogh, 2014). The close family members must be actively involved because of the need to monitor the patients and identify whether or not the interventions are having positive or negative effects. For instance, antidepressants have been said to bring suicidal thoughts to children, and, therefore, close monitoring of the patients is necessary.

During child sessions, there is need to ensure that the children understand that the therapy sessions are not a form of punishment and that their condition is not abnormal but rather something that they can overcome (Weisz & Kazdin, 2010). The therapist has to create an environment that allows the child to embrace what is going on and feel like it is good for him or her. In many cases, children may not understand why they have to go to psychotherapy sessions, or some of their friends at school may tease them about these sessions and, hence, make them feel inferior or develop dislike for psychotherapy. The child has to be reassured every time that he or she is doing a thing that he should be proud of. He or she should see the therapists as friends who mean well (Reinholt & Krogh, 2014).

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Conclusions

Generalized anxiety disorder is one of the mental disorders that may have a grave toll on children and adolescents considering that these young people are still at a stage where their minds are developing. Since GAD affects the confidence of children, these young people need a lot of support from their parents, friends, and close relatives. GAD also affects interpersonal relationships whereby the adolescents affected may not have normal social relationships which are an important stage of their development. It is, therefore, important that therapy sessions take into account the aspects of development with regard to interpersonal relationships so that, at the end of the day, these young people could be more confident about themselves and, thus, have more vibrant relationships with others.

The paper is devoted to the Middle East Respiratory Syndrome Coronavirus, which has recently become known due to the severe symptoms and consequences. The paper concerns the general information on the virus (its size, classification, etc.), the causes of its emergence and spread. Along with this, the paper is full of the information of the possible diagnostic and preventative measures, which are to keep a person from getting infected with the Middle East Respiratory Syndrome Coronavirus. The relevance of Middle East Respiratory Syndrome Coronavirus had been mainly associated with the intensification of migration processes, including increasing the labor migration’s level, tourism, and business travels, particularly in the regions that were previously – due to limited transport services – not available, or the journey lasted for several weeks or months, etc. This facilitates the rapid movement of the sources of infectious agents (i.e. infected people) across the globe, delivery agents in the territory of non-endemic for a particular infectious disease. None the less, the conditions for the implementation of microorganism transmission mechanism is the emergence of epidemic outbreaks, epidemics, and even pandemics.

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Keywords: Middle East Respiratory Syndrome Coronavirus, infection, disease’s environment, treatment, mortality.

Success in the fight against infectious diseases, which was achieved in the middle of the 20^th century, has created the illusion of emergency to eliminate them. However, in the following decades, this misconception was refuted due to the reason that it showed that infectious diseases continued to cause enormous economic losses to society. In all countries, regardless of their level of economic development, there has been a marked increase in the incidence of infectious diseases and epidemics recorded. The end of 20^th century and the beginning of the 21^st century were characterized by the appearance of several new pathogens to human viral infectious diseases.

The original and initial source of the virus still remains unknown, but the nature of transmission of the virus and virological studies indicate that the reservoir of the virus in nature are dromedaries of the Middle East. The mode of transmission is airborne and food (by consuming infected camel’s milk or insufficiently heat-treated meat in endemic regions). Coronaviruses can also be detected in the feces and urine. Therefore, the purpose of this paper is to investigate the nature, prevention, causes and possible treatment of the Middle East Respiratory Syndrome. In order to achieve this goal it is extremely important to review the most recent investigation on this issue.

Middle East Respiratory Syndrome Coronavirus: Background information

The Signs and Symptoms of the Disease

The clinical manifestations of the Middle East Respiratory Syndrome  are generally similar to other clinical manifestations of acute respiratory diseases, so the differential diagnosis is to be based on laboratory methods (primarily in the polymerase chain reaction) and epidemiological data. The incubation period is researched to be usually 5-6 days, but may be in the range of 2 – 14 days (Song & Sutter, 2014). Middle East Respiratory Syndrome Coronavirus is clinically characterized by such symptoms are fever, cough, shortness of breath, difficulty breathing, and in the majority of clinically confirmed cases quickly become severe primary viral pneumonia. Patients suffer from chronic diseases of respiratory and cardiovascular systems, metabolic syndrome and immunodeficiency states of various origins, in the foreground may be nominated by symptoms of the gastrointestinal tact (diarrhea) and renal failure.

In this case, the World Health Organization (WHO) recommends considering as a possible Middle East Respiratory Syndrome Coronavirus ​​require appropriate laboratory confirmations, sanitary measures and hospital monitoring of all the cases of acute respiratory illness in the presence of epidemiological evidence (if a person stays in the Middle East for 14 days before the onset of clinical manifestations).

All the described light and asymptomatic cases of Middle East Respiratory Syndrome Coronavirus are currently worrying the experts because of the possibility of hidden spread of the disease, although the real assessment of the likelihood of such a scenario is still uncertain. Almost 95% of all cases of diagnosed Middle East Respiratory Syndrome Coronavirus appear in the Middle East, including a wide margin in the lead of Saudi Arabia and the United Arab Emirates (948 and 74 observations, respectively) (Song & Sutter, 2014). There is the appearance of alertness of the Middle East Respiratory Syndrome Coronavirus in Egypt, where, as this is located in the Arabian Peninsula, there are significant populations of bats and camels  that determine the possibility of the formation of secondary natural foci.

The Middle East Respiratory Syndrome Coronavirus is not limited to its natural foci of the base area, and as an imported infection is registered in Africa (Algeria, Egypt, Tunisia), Europe (Austria, France, Germany, Greece, Italy, Netherlands, Turkey, France), Asia (Malaysia, Philippines), America (USA).

Data on the Virus

The virus of the Middle East Respiratory Syndrome Coronavirus has a spheroid shape (120-140 nm), is provided with a lipid envelope with clearly distinguishable peplomerami on electron micrographs, whose club-length is 5 – 10 nm with the formed trimers of protein S (~ 200 kDa) (Song & Sutter, 2014). The appearance of the virus is showed on the picture (Fig. 1).  

Fig. 1.

Middle East Respiratory Syndrome Coronavirus has attracted particular attention of experts in the field of biological safety, as its known natural foci are found in the Middle East – in the region, with increasing political, social and economic tensions that could also provoke a “flare-up” and “smoldering” epidemic situation.

The discovery of the Middle East Respiratory Syndrome Coronavirus took place in June and September 2012, when in the hospital in Jeddah (Saudi Arabia), a 60-year-old man died. Nasopharyngeal wash was sent to a laboratory (Song & Sutter, 2014). A model of African green monkey (Vero) and makakirezus (LLC-MK-2) cell lines transplanted kidney was obtained from the virus with an isolate pronounced cytopathic effect. Polymerase chain reaction with universal coronavirus primers allowed the identification of primary Coronaviridae pathogen as a representative of the family.

Currently, the status of Middle East Respiratory Syndrome Coronaviru is as follows: a squad of nidovirales, a family of Coronaviridae, a subfamily of Coronavirinae, born as Betacoronavirus, subgenus. Nidovirales contains infectious enveloped viruses with a single segment of the linear single-stranded RNA of positive polarity, which has a number of common features of genome organization, replication, and its expression. This group, in addition to Coronaviridae, includes two other families: Arteriviridae and Roniviridae. The first combines the mammalian viruses, but not the human-related (including virus of arteritis virus, reproductive and respiratory syndrome), the second one is only presented by the viruses of arthropods.

The Pathogenesis of Infection

The virus is transmitted by airborne droplets and through contact with body fluids of the patient. There is information about the presence of the virus in secretions of sweat glands and the possibility of transmission through contact with sweat. Given the presence of the virus in faeces, clarifies the possibility of implementing the fecal-oral mechanism of transmission.

However, today more and more researchers believe that animal coronaviruses of Middle East Respiratory Syndrome Coronavirus fecal-oral transmission mechanism are no big deal for distribution. In hospitals, the factors of transmission may be subject to common use, artificial respiration apparatus, other medical instruments that touched to mucous membranes of humans (Berger, 2015). The period of contagiousness is at the beginning of clinical manifestations and lasts during the height of the disease, some patients may be observed in the phase of recovery. Professional groups at risk of infection are health workers, who provide assistance to the injured people, as well as the personnel of diagnostic and research laboratories.

The results of molecular genetic studies showed that the natural reservoir of the pathogen is bats. There is a possibility of transmission to humans through products of bats living in the attics of apartment buildings. There is a possibility of transmission from a person to a person in close contact (including health care workers).

The clinical picture of Middle East Respiratory Syndrome Coronavirus is an acute viral respiratory disease (spreading of respiratory desists), which is accompanied by fever, cough, shortness of breath, wheezing and, in most clinically confirmed cases, quickly turns into severe primary viral pneumonia (Berger, 2015). Patients suffer from chronic respiratory diseases and cardiovascular, metabolic syndrome and immunodeficiency of the various origins, to the fore as leading symptoms appear lesions gastrointestinal (diarrhea) and renal failure.

The recent research study on Middle East Respiratory Syndrome Coronavirus

Volz et al. (2015, p. 8651) have a conviction that “Middle East respiratory syndrome coronavirus (Middle East Respiratory Syndrome Coronavirus) emerged as the causative agent of severe human respiratory disease in Saudi Arabia.” Thus, the purpose of their study was to prove the fact that antibody elaborated is to contribute to the disease treatment. The hypothesis of the investigation is the fact that mice who have been intentionally infected obtain a positive treatment by the usage of the antibody.

In this connection, the WHO has developed and proposed a questionnaire to be used for the initial investigation of the Middle East Respiratory Syndrome Coronavirus. When a special relevance diagnosis with laboratory methods research is inserted, the samples of body fluids with lower respiratory tract should be a priority for the collection and study of real-time reverse transcriptase polymerase chain reaction (PCR Roth). Mouth-PCR testing samples of the lower airways are more sensitive to detect coronavirus of the Middle East Respiratory Syndrome Coronavirus, than the test samples of the upper respiratory tract.

The major finding of the investigation by Volz et al. (2015) consist in the fact that the authors believe, the priorities include respiratory samples from the lower parts of the respiratory system. Serum sample should be obtained for serological testing. Data from the selected cases to date indicate that the lower respiratory tract samples (Sputum, tracheal aspirate, bronchoalveolar lavage fluid (BLF)) are more sensitive for detection of Middle East Respiratory Syndrome Coronavirus using mouth-PCR tests than those, which have been collected from the upper respiratory tract (in conjunction with the nasopharynx and oropharynx, nasal aspirate).

WHO and the US Centers CDC published recommendations for the prevention and control of Middle East Respiratory Syndrome Coronavirus infection in hospitals. The increase of the level of infection control measures is recommended in caring for patients with the alleged or confirmed cases of Middle East Respiratory Syndrome Coronavirus infection (Berger, 2015). WHO recommends that standard precautions for infection prevention droplet can be used when caring for patients with acute respiratory tract infections.

The importance of the study by Volz et al. (2015) consists in the fact that protective equipment should be added in the care of alleged or confirmed cases of Middle East Respiratory Syndrome Coronavirus infection. Barrier precautions should be used for the performance of medical procedures. Temporary home care and isolation are possible in some cases, as CDC recommends, so that patients who are currently rated as a possible case of Middle East Respiratory Syndrome Coronavirus infection and do not require hospitalization, they can be isolated in their home in the community.

The recommendations of WHO stated that individuals at high risk of severe disease (immunodeficiency, diabetes, chronic lung disease, signs of kidney failure) should not visit farms, sheds, markets, places where there are camels. The preventive measures include avoiding contact with camels, evolving the personal hygiene, stopping consuming raw camel milk as well as the raw and insufficiently heat-treated meat.

One of the most interesting points of the article by Volz et al. (2015) is that clinically, severe respiratory syndrome manifests itself with the development of renal failure. The main symptoms are fever, malaise, weakness, headache, cough, shortness of breath and myalgias. In 1/3 of patients, gastrointestinal symptoms (diarrhea, vomiting, abdominal pain) may develop.

Volz et al. (2015) have a conviction that Middle East Respiratory Syndrome Coronavirus should also involve patients with acute respiratory disease of any severity, which during the previous 14 days of the disease were in close contact with patients with suspected or confirmed case of the Middle East Respiratory Syndrome Coronavirus.

Mortality in severe Middle East Respiratory Syndrome Coronavirus, as the most recent investigations show, is 35-40% higher in patients, who are older than 65 years and with severe comorbidities (Song & Sutter, 2014). Specific prevention and treatment is heliotrope. For laboratory diagnosis of disease, the  PCR material of the lower respiratory tract (sputum, endotracheal aspirate, bronchoalveolar lavage) and serum are expected to be performed. If the patient has no signs or symptoms of lower respiratory tract infection and sampling of the lower respiratory tract is not possible or is not clinically indicated, it is necessary to take a sample of nasopharyngeal or oropharyngeal. These two samples can be combined in one container and be tested together. If a patient with a probable case of infection caused by Middle East Respiratory Syndrome Coronavirus, initial testing of nasopharyngeal sample was negative, the patient should be evaluated by using a sample from the lower respiratory tract or repeat nasopharyngeal specimen with additional oropharyngeal sample (if it is impossible to take a sample from the lower respiratory tract) (Rossi & Hui, 2016).

In health care organizations to comply with sanitary and anti-epidemic mode (mode of ventilation, air disinfection, control over the patients visiting relatives, and others) there is a timely transmission of information about probable or confirmed case of infection caused by Middle East Respiratory Syndrome Coronavirus (Rossi & Hui, 2016). There should be a laboratory examination of patients with a probable case of infection caused by Middle East Respiratory Syndrome Coronavirus, laboratory examination of all health workers, who become ill with severe acute respiratory infection (hereinafter – SARI), who provided care for patients with SARI.

There should be a raising awareness among all health care workers of the possibility of cases among people infection caused Middle East Respiratory Syndrome Coronavirus and requirements for the notification of such cases; conducting outreach with the public about the possibility of Middle East Respiratory Syndrome Coronavirus infection when visiting the Middle East, South Korea, paying attention to the fulfillment of prevention rules.

It is important to see the way the Middle East Respiratory Syndrome Coronavirus produces the antibody response. The investigation which has been conducted by Volz et al. (2015, p. 8653) shows that “repeated i.m. immunization further increased the levels of Middle East Respiratory Syndrome Coronavirus-neutralizing antibodies to higher titers than those obtained upon s.c. immunization. However, the peak antibody titers elicited by s.c. and i.m. immunizations did not differ significantly.” This is illustrated on the graph, which is located below.

Fig. 1 (Volz et al., 2015)

Additional investigation on the nature of Middle East Respiratory Syndrome Coronavirus has been conducted on mice by Volz et al. (2015). This investigation showed particularly significant results which concern glycoprotein of Middle East Respiratory Syndrome Coronavirus. Thus, the authors state that “an examination of the efficacy of MVA-MERS-S vaccination in a mouse model of Middle East Respiratory Syndrome Coronavirus lung infection revealed that all of the immunized mice exhibited little or no replication of Middle East Respiratory Syndrome Coronavirus” (Volz et al., 2015). This means that the vaccination is likely to serve as a curing (and probably preventative) tool for the disease treatment. This result is regarded as positive.

In addition to this, the authors mention the fact that “these data confirm that the S glycoprotein of Middle East Respiratory Syndrome Coronavirus… is an important and safe vaccine antigen” (Volz et al., 2015, p. 8655). Thus, it is possible to conclude that the antibody used can help in the disease treatment and save human beings’ lives. As a consequence, the scholars “found no evidence of an increased inflammatory response or the potential enhancement of Middle East Respiratory Syndrome Coronavirus infection through S-antigen-specific antibody induction” (Volz et al., 2015, p. 8655), which helps recall the previous investigation, where “as has been previously speculated for SARS-CoV infections” (Volz et al., 2015, p. 8655). Finally, Volz et al. (2015, p. 8655) make a conclusion that “thus, the MVAMERS-S vector merits further development as a candidate vaccine against Middle East Respiratory Syndrome Coronavirus for potential human use.” It means that the usage of antibody, from both theoretical and empiric points of view, stimulate the disease’s stop and make a contribution to the positive results of treatment.

Description and discussion on either environmental or other factors contributing to the emergence of Middle East Respiratory Syndrome Coronavirus

Middle East Respiratory Syndrome Coronavirus is known to be caused by a new coronavirus, Beta-identified as Middle East Respiratory Syndrome Coronavirus. Clinical manifestations are characterized by high fever, lesions of both upper and lower respiratory symptoms of pneumonia, development of acute respiratory distress syndrome (ARDS). Frequently, there is enough observed exacerbation of chronic somatic diseases. These two properties are the main causes of fatal consequences.

Humanity is facing new diseases mainly viral etiology characterized by the occurrence of unpredictable and difficult course. This often leads doctors around the world to a scientific dead end, figuratively speaking. Here, it is possible to recall, for example, a disease caused by the Ebola virus. The emergence of diseases are caused by unpredictable antigenic variability of the virus, which is associated with spontaneous or emerging population immunity under the influence of qualitative changes antigenic determinants.

A clear confirmation of the above-mentioned facts was cases of fatal diseases caused by coronavirus of Middle East respiratory syndrome. The relevance of infectious disease is associated with increasing migration, the number of tourist and business voyages, particularly in those regions that were previously impossible.

During the period September 2012 – June 2015 the World Health Organization officially informed of the 1289 laboratory confirmed    Middle East respiratory syndrome cases caused by the Middle East respiratory syndrome in the world, 455 cases were fatal of which (Song & Sutter, 2014). The mortality rate is 35.3% (Song & Sutter, 2014). The largest outbreak of Middle East respiratory syndrome has been fixed outside the Arabian Peninsula in South Korea. The first report to WHO was received May 21, 2015. As of 15/06/2015, 150 registered  cases, of which 17 (11.3%) are deaths (Song & Sutter, 2014). Medical observation is made on more than 5 thousand people who were in contact with laboratory confirmed to the Middle East respiratory syndrome individuals.

The natural environment for the Middle East respiratory syndrome  are bats (Chiroptera: Microchiroptera). The bats naturally infected Weaver (Viverridae), which are the inhabitants of the South-Eastern Asia looked after as pets and are often used in food. The most likely way of penetration of Middle East respiratory syndrome in human populations is as follows,

 → bats, small wild mammals (Himalayan civet, a raccoon-like dogs, badgers birmenski) → Meat defective heat treatment restaurants → people (Song & Sutter, 2014).

The natural environment of the coronavirus is the results of the molecular genetic analysis, which found that the main transporters of the disease are bats. Studies in Europe, Africa and Asia, including the Middle East have shown that a similar coronavirus of RNA sequence is often found in samples of feces of bats and that some of these sequences which are closely associated with the sequence of Middle East Respiratory Syndrome Coronavirus. Bats can be a reservoir of Middle East Respiratory Syndrome Coronavirus, but it is unlikely that they are the direct source for Middle East respiratory syndrome disease, because human contact with bats is frequently uncommon.

Possible sources and routes of transmission are likely to be camels (dromedary) – the main owner of Middle East Respiratory Syndrome Coronavirus in animals. Convincing evidence of transmission of Middle East Respiratory Syndrome Coronavirus camel to man had been studied in Saudi Arabia. In the process of complete genome sequencing revealed that the viruses isolated from man and his camel were identical.

The studies show that the Middle East Respiratory Syndrome Coronavirus can be transmitted from a camel to a camel and from them – to people in close contact. Availability of the thematic clusters, which have been epidemiologically confirmed, suggests the transmission of the virus from person to person through close contact occurs, especially in the provision of care to such patients.

Glossary

The following terms are to be defined for the better understanding of the topic issue.

Middle East Respiratory Syndrome is mainly regarded as a zoonotic virus, which is transmitted from animals to humans. The origin of this virus is not known to a full extent; however, according to the analysis of various virus genomes, it is frequently believed that it originated among the bats and was handed over to the camels in the remote past (“MedlinePlus – Health Information from the National Library of Medicine”, 2016).

Fever is an abnormal rise of the body temperature. This term is a key symptom during the Middle East Respiratory Syndrome (“MedlinePlus – Health Information from the National Library of Medicine”, 2016).

Conclusion

Middle East Respiratory Syndrome Coronavirus infection can occur as virtually asymptomatic, and with the defeat of the upper respiratory tract, with the rapid development of pneumonia, respiratory failure, acute respiratory distress syndrome, as well as with the development of septic shock and multiple organ failure. Most often, Middle East Respiratory Syndrome Coronavirus infection is recorded in adults, although there are cases of the disease in children.

For the diagnosis of Middle East Respiratory Syndrome Coronavirus primarily epidemiological history data is used. It is important to know, whether the patient visited endemic areas of the Middle East and other countries where cases have been recorded Middle East Respiratory Syndrome Coronavirus. Furthermore, it is important to know whether there was contact with the patients, who visited the country of the Arabian Peninsula, or those who suspected Middle East Respiratory Syndrome Coronavirus. All patients who are suspected of Middle East Respiratory Syndrome Coronavirus, in accordance with the instructions on the management of patients, are examined for the presence of bacterial infection. It is recommended that sampling has to be prior to antibiotic therapy. Material for the study is to be taken as from the upper and lower respiratory tract of a nasal swab, nasal and / or throat; sputum, tracheal aspirate, bronchoalveolar lavage.

It is important to keep ot of traveling to Saudi Arabia, Qatar, the United Arab Emirates without any urgent need. When leaving in these countries, if necessary, it is recommended to use the protective masks and refrain from visiting crowded places and contact with sick people with fever. When leaving the country in the Middle East region people should avoid contacts with camels and eating raw foods derived from camels (milk, meat). If experiencing respiratory symptoms, wear a mask and immediately seek medical attention. When a fever or flu-like symptoms when returning from a trip need time to consult a doctor, providing information about the countries visited and the duration of bacterial infection. It is recommended that sampling prior to antibiotic therapy. Material for the study was taken as from the upper and lower respiratory tract of: nasal swab, nasal and / or throat; sputum, tracheal aspirate, bronchoalveolar lavage.

In order to prevent infection of coronavirus  infection is recommended to refrain from traveling to Saudi Arabia, Qatar, the United Arab Emirates without urgent need. When leaving in these countries, if necessary, recommend the use of protective masks and refrain from visiting crowded places and contact with sick people with fever. When leaving the country in the Middle East region should be avoided contacts with camels and eating raw foods derived from camels (milk, meat). If experiencing respiratory symptoms, wear a mask and immediately seek medical attention. When a fever or flu-like symptoms when returning from a trip need time to consult a doctor, providing information about the countries visited and the duration of stay.

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Cancer may affect any organ of the human body. It is an oncological medical condition caused by erratic and uncontrollable cell division and growth that eventually develops into a malignant tumor. The human body consists of certain tissues, which in turn are built of millions of cells. Every tissue has its special cellular texture with strictly-ordered cells in it. Old or affected cells are replaced by the new ones when required. Normally, cell growth and division is connected with the formation of new cells in response to the body’s needs. The damage of cellular texture accompanied with sequential cell division causes malignant diseases. Uncontrollable division of mutated cells facilitates the formation of lumps and masses of tissues that are called tumors. Tumors can significantly interfere with various systems of the body such as nervous, digestive, urinary, and circulatory due to their rapid development. Additionally, the hormones released by the tumors substantially impair body functioning. There are two types of tumors: benign and malignant. Benign tumors are characterized by constrained growth and unchangeable location. They primarily do not affect nearby tissues and remain localized in the original place. Unlike benign cells, malignant ones are more dangerous due to their ability to infiltrate into healthy tissues and travel all over the body, affecting lymphatic and blood systems. Cancer is frequently associated with the development of metastasis or metastatic spread, which is the process of cancer cells shifting from the starting location and lodging into other tissues and parts of the body, where abnormal cells can start an uncontrollable growth cycle.

There are various types of cancer due to the variety of cancer cells. However, it is a well-known fact that malignancies originate from normal cells that undergo multiple severe mutations, which transform them into cancerous cells. Normal cells traditionally have certain a strict proliferation, pass signals to stop it, produce “substances called adhesion molecules” that provide their fine location and go through apoptosis, the programmed death of cells; and cancer cells do the opposite (Eldridge). Malignant cells stop responding to many different “signals controlling cellular growth and death” (“Essential of Cell Biology”). Abnormal cells spring from adjoining tissues and start their rapid multiplication and growth that cause critical disturbances in the cell programming. A damaged cell program leads to immortality of cancer cells. They demonstrate an ability to multiply even if they it is not required. Furthermore, damaged cells fail to respond to “self-termination signals” that command to stop growing or die, so-called apoptosis, at cell’s senescence or damage (Bailey). The damaged cells are prone to overcrossing their boundaries, penetrating the nearby tissues. Such invasiveness complicates surgery on cancerous tumor removal. Unlike normal cells, cancerous ones experience a deficit of special adhesion molecules that are responsible for sufficient stickiness of cells. Such deficiency allows them shifting and floating inside the body and consequently damaging other organs and tissues. Additionally, malignant cells learned how to “restore their telomeres,” a specific chromosome’s structure responsible for the cell’s lifespan, which enables them to achieve immortality. Specific gene mutations result in impossibility of cells’ self-destruction. Furthermore, they are hardly detectable due to their ability to hide among normal cells and shape their properties. Due to such abilities, cancer cells manage to “evade detection or inactivate the immune cells” (Eldridge). They undergo gene and chromosome mutations that impair relevant cell reproduction. Malignant cells can induce normal cells to create their own blood vessels for delivering oxygen and nutrients to the tumor. Moreover, they consume a large amount of glucose required for rapid division and growth. Thus, malignant cells possess properties that allow them surviving under any circumstances. Uncontrollable growth, invasiveness, propensity to metastatic spread, and immortality are also distinctive peculiarities of cancerous cells.

As it has already been specified, there are a great variety of cancers that may impair any organ or system of the body, and the blood system is not an exception. One may be aware of such illnesses as leukemia and lymphoma that disrupt the functioning of the entire blood system. Lymphoma or lymphatic cancer is a dangerous disease that severely damages cells and organs of the blood system and can substantially reduce a person’s life expectancy. The disease affects lymphocytes, the cells of the immune system and consequently compromises the entire immune system. They comprise approximately 25% of white blood cells and include B and T cells. B cells participate in the antibody response, and while T cells are responsible for cellular immunity. The mutagenesis of lymphocytes and their further transformation into malignant ones signify lymphatic cancer. Multiplication and gradual accumulation of altered lymphocytes inside the body promote further spread of lymphomas. Oncologists report that “the cellular misadventures in blood-forming cells or lymphocytes and aberrations of normal cell process” may provoke “oncogene formation and inadequacies in DNA repair mechanisms” and lead to the most severe blood cancerous afflictions (Lichtman).

Lymphoma is one of the most common blood cancers in the USA. It is the seventh most frequent cancer in adults and the third one among cancers in children. Non-Hodgkin’s lymphoma is diagnosed more frequently than Hodgkin’s type. In 2016, 81,080 people were expected to be diagnosed with lymphomas, and 21,270 people could die from the disease. Approximately 800,000 patients live with the disease in the USA. The represented statistics shows the growing incidence and high mortality rates of the illness.

There is a great variety of lymphomas, such as Hodgkin’s, non-Hodgkin’s, Birkitt’s, T-cell and B-cell lymphomas, lymphoproliferative lymphomas, and others. However, Hodgkin’s and non-Hodgkin’s lymphomas are the most frequent ones. According to the American Cancer Society, Hodgkin’s lymphoma affects lymphatic tissues or lymph nodes, and Non-Hodgkin’s type of lymphatic cancer is “cancer that starts directly in cells called lymphocytes.” Essential impairments in the lymphocytes’ DNA ignite the development of the stated disease. “The altered DNA in the lymphocyte produces a cancerous change” that can lead to the “uncontrollable growth of the cancerous lymphocyte” (Walter). Unchecked multiplication of the damaged B-lymphocytes, or so-called Reed-Sternberg cells, that hugely affect the lymphatic or reticuloendothelial systems identify Hodgkin’s lymphoma. Non-Hodgkin’s lymphoma primarily damages B or T-cells that may penetrate into lymphoid tissues, including lymph nodes or any other organ of the body. Thus, different kinds of lymphoma substantially damage various lymphocytes and lymphatic tissues. The disease may spread to other organs as a result of mutagenesis.

Lymphomas usually have four stages, and each of them signifies the spread of the illness from one starting spot to another site of the body. The first or the early stage of the disease indicates the damage of a single lymph node or a single lymphatic site. It simultaneously shows if cancer affects “a single extra-lymphatic site without involving any lymph nodes” (Bonander). The second stage identifies localized progressing of the disease that afflicts two or more lymph nodes that are placed on the same side of the diaphragm. In this phase, lymphoma can move close to any tissue or lymphatic organ. The third stage is the advanced stage of the disease, when cancer severely affects two or more lymph nodes, or can damage one lymph node or organ located on both sides of the diaphragm. The distinguishing feature of the third stage is the involvement of “the spleen or extra-lymphatic extension” into mutation (Bonander). Finally, the fourth stage indicates the spread of lymphoma beyond lymph nodes and spleen to another site or organ. In the last stage, cancer can infiltrate liver, bone marrow, bones or the central nervous system. “Diffuse or disseminated involvement of one or several extra-lymphatic organs” with or without damaging lymph nodes specify the fourth and the most dangerous stage of lymphoma (Bonander). The present classification is helpful for choosing adequate therapy that would be efficient for a particular stage. There are lots of factors associated with the significant risk of acquiring a lymphoma; however, the exact causes of lymphomas remain unknown. Nevertheless, medical researchers managed to define specific risk factors that may influence the incidence of lymphoma. It is evident that people of different age can develop the symptoms of lymphoma. It is also a fact that the elderly are more prone to this medical condition. Children are at risk of having lymphomas if they experience some “immune deficiency disorders” or have contracted a specific virus (Fayed). The presence of such infections as Helicobacter pylori infection, T-cell leukemia virus, Epstein-Barr virus, Kaposi’s sarcoma-associated herpes virus, and Hepatitis C are the causative agents peculiar for a certain kind of lymphoma. Patients affected by some autoimmune disorders or suffering HIV/AIDS are susceptible to lymphomas of any kind due to the vulnerability of their immune system. There are also definite genetic and environmental risk factors that increase the risk of developing lymphoma. Radiation, pollution, chemical and viral exposure relate to environmental causes of lymphoma. The presence of a lymphoma-afflicted person in the family also increases the probability of developing the same disease in the future. Patients who undergo chemotherapy or radiation therapy or receive immunosuppressive medication after transplantation are also at risk of developing lymphoma. Furthermore, belonging to a certain sex or race can be an alternative triggering factor for some types of the disease. Thus, age, compromised or depressed immune system, exposure to specific viruses and infections, chronic diseases, chemical and radiation exposure, living in the polluted areas are the most predominating factors that predispose the development of lymphatic cancer.

During their maturation, lymphocytes go through the differentiating process that specifies responsibilities of lymphocytes inside the immune system. If this process is disturbed, lymphatic malignancies can occur. Malignant cell transformation implicates the interfered regulating mechanism of genes functioning and the damage of genome stability. The deficit of immune response, such as imbalance of cytokines production and genetic impairments connected to T-cell receptor immunoglobulin rearrangement may contribute to lymphoma development. Genetic abnormalities related to lymphatic cancer can be divided into 2 categories: proto-oncogenes activation and deactivation of genes responsible for malignancy suppression. The main mechanism of proto-oncogenes activation in lymphatic tumors is chromosome translocation. Proto-oncogene is frequently placed on one of the partner chromosomes near the recombination spot. The proto-oncogene is anatomically intact but its expression regulation is defected. At Non-Hodgkin’s lymphoma, proto-oncogene frequently dislocates to the immunoglobulin gene locus and comes under control of heterological elements that regulate gene expression on the partner chromosomes. It results in the constant proto-oncogene expression. Lymphoma rarely occurs due to translocations. On the contrary, it can appear in case of place and time factor coincidence. Considering multifactor nature of lymphoma, genetics came to a conclusion that amalgamation of genes responsible for predisposition to lymphomas forms a network of interlinked elements. Furthermore, the result of such interconnection and interaction on the protein level predestinates biochemical susceptibility of a human being to blood cancers, including lymphoma. The presence of genetic polymorphism explains the variability of malignant progression. Thus, various genetic alterations can lead to mutagenesis and development of such blood cancer as lymphoma.

Lymphomas can spread to distant sites of the body. However, metastasis is not very common in lymphoma; that is why “the notion of metastatic lymphoma becomes a little more complicated” (Bonander). Metastatic lymphoma rarely forms a tumor in the body remotely. Such tumor is frequently disclosed in the lungs, spleen or in the central nervous system.

Since all kinds of lymphoma are equally dangerous, the appropriate treatment is rather crucial for achieving recovery. Lymphoma is considered one of the most curable cancer diseases, particularly in case of early diagnosis. The scrutinized affliction primarily involves a broad usage of chemotherapy and radiation therapy. Chemotherapy appears to be the most frequent and efficient treatment modality involved in the lymphoma medical management. It is aimed at destroying malignant cells, preventing their further reproduction, and shrinking tumors. Chemotherapy medicines are used for attacking cells that divide rapidly. However, this kind of treatment may produce adverse effects due to the capability of specific drugs to destroy not only cancerous cells but also “harm normal, noncancerous cells as well” (LymphomaInfo). Lymphoma patients can take either a single drug or a combination of them, which depends on the severity of the disease. As stated above, radiation is also a medical tool to treat lymphoma. John Walter in his booklet “Hodgkin Lymphoma” clarifies the purpose of the applied therapies: radiation therapy concludes in “targeting the evident Hodgkin’s lymphoma cell masses while chemotherapy is meant for killing lymphoma cells” (Walter). High doses of X and gamma rays or other alternative types of ionizing can destroy malignant cells and shrink tumors. For some kinds of lymphoma, oncohematologists frequently utilize a combination of chemotherapy and radiation therapy if the usage of the one of the stated curing methods is insufficient and does not demonstrate any improvements. Lymphoma treatment may involve surgical intervention if tumor removal is required. The complicated cases of lymphatic cancers require bone marrow or stem cell transplantation, which implicates wiping out the entire immune system, including the bone marrow that produces blood cells, and transplantation of a healthy bone marrow. Additionally, there are such treatment modalities as immunotherapy and radioimmunotherapy. At immunotherapy “the body’s immune system is trained to attack and remove tumor cells” (“Immunotherapy”). The combination of monoclonal antibody therapy and radioactive isotopes specifies radio-immunotherapy, which is mostly designed either for refractory or relapsed lymphomas. Any treatment therapy can be highly efficient in case of a comprehensive and early diagnosis.

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Medical treatment largely depends on the type of lymphoma and its stage. Furthermore, health care providers must consider the patient’s health condition, his or her age, the location of the malignant tumor, and physical maturity. These factors are important for developing treatment planning that can be efficient for recovery or long-term remission. Practically all therapies involved in the lymphoma medical management are aggressive and can badly affect the immune system of the lymphoma-affected patient. Therefore, it is crucial to take all necessary precautions to prevent any infections or viruses and avoid any suspicious contacts that can deteriorate the patient’s condition. Any treatment modality can be associated with certain adverse effects. Chemotherapy as well as radiation therapy may cause various complications or even other secondary cancers that can occur after treatment, which is why health care providers must closely supervise patients undergoing lymphoma treatment. In case the patients do not respond to any treatment, they can participate in some clinical trials that test various alternative medicines and therapies.

In conclusion, various cancers considerably threaten people’s life today. The peculiar features and properties of malignant cells point to their insidious nature and complexity. Mutations occurring inside cells cause a variety of cancers, and blood malignancies relate to them as well. Lymphoma is a type of blood cancer that drastically damages lymphocytes and infiltrates lymphatic tissues and organs. In this case, lymphocytes undergo considerable mutations. The medical condition demonstrates a significant mortality and morbidity rate, which is why it is the issue of serious concern for many medical researchers and patients all over the world. Everybody is at risk of having lymphoma due to a wide variety of risk factors that people can be exposed to. To reduce the risk of developing lymphoma to the minimum, one should keep a healthy lifestyle and have regular check-ups to be able to diagnose and combat the disease at the earliest stage. There are various highly efficient medications and treatment modalities that provide recovery or long-lasting remission of lymphoma patients. However, the death statistics of blood cancer patients suggests that even the existing therapies are sometimes helpless in curing lymphomas.

The Role of Neurotransmitters

All actions of depend on neurons, which communicate with one another. It is possible because of neurotransmitters, which are natural brain chemicals that send signals to other parts of the human brain and the body. In other words, they carry chemical messages amid neurons. The process of impairing neural networks that involve chemicals and changing the function of nerve receptors and systems may cause depression. Neurons can communicate among themselves in the electrical form, for example, in areas of the human brain which control movements. In case such electrical signals become abnormal, they can be a reason for symptoms or tremors, which characterize Parkinson’s disease (National Institute of Mental Health, n.d.). Therefore, when neurotransmitters do not work correctly, their action can cause certain psychological disorders. Considering new tools in both genetics and neuroimaging, it should be mentioned that they help scientists make progress in exploring factors that cause mental disorders (Weir, 2012). Thus, psychological diseases possess multi-factorial etiologies, including a complex interplay between neurotransmitters, environmental and personal (genetic) factors.

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Biological/Personal Causes of Psychiatric Diseases

A psychological disease is more common in individuals whose blood relatives have a mental disorder. Certain genes can increase the risk of developing the latter, and any life situation of that person may trigger it. According to the studies conducted on identical twins and mentally ill parents with their children, scholars indicated the relation between a genetic component and a psychiatric illness (National Institute of Mental Health, n.d.). However, the statement that the latter is hereditary is inaccurate. To be a hereditary trait, it must be passed in a direct way from one generation to the following; for example, from one grandparent to his/her grandchild. Although a mental disease is often present in families, it is not as hereditary as eye color or male pattern baldness. On the other hand, a psychiatric disorder is heritable meaning that humans inherit genes, which make them susceptible to it. As such, an illness is not a trait and cannot be passed directly from a mother or a father to a child. However, genes have the potential to make any mental disease active, and only they can be transmitted from one parent to the child (National Institute of Mental Health, n.d.). Thus, a mental disorder is indeed a genetic illness.

Taking into account the human brain, it can also be a cause of a psychiatric disorder because its structure, including neurochemicals and other molecules, can make it sensitive to any mental illness. For example, a traumatic brain injury, such as a violent hit on the head, can be a reason for developing a mental disease. Among other personal factors that can cause psychological disorders, there are problems during gestation or birth, alcohol abuse, recreational drugs, and such traumatic experiences as being assaulted or involved in a military combat (Weir, 2012). Thus, genetics and personal characteristics play an important role in developing mental diseases.

Environmental Causes of Psychiatric Diseases

Considering the major causes of psychological disorders, researchers also pay their attention to the environment because it is the world where an individual lives and functions differently depending on external factors (Schmidt, 2007). Although it is a broad category with an extensive list of conditions, some of them are the most common causes of psychiatric diseases. Many people live being attacked by stressful life events, which are caused by various chronic stressors, such as social struggles or economic hardships. Experiencing severe trauma, such as sexual abuse, kidnapping, or torture, can increase the percentage of individual’s exposure to such mental illnesses as post-traumatic stress disorder (PTSD). Victor Carrion, a professor of psychiatry at Stanford University School of Medicine, suggested that such terrifying experience in combination with genetic vulnerability can double person’s risk of developing PTSD (as cited in Schmidt, 2007). A low quality of human life due to poverty or poor nutrition is also a reason for developing certain mental diseases. Exposure to toxins, especially at certain developmental stages, can contravene the normal functioning of the human brain and the body. Thus, it is also a basis for a psychiatric disorder. Any family or relationship issues, child violence, and lifestyle considerations related to substance abuse are also common environmental factors leading to mental illnesses. Although extreme adversities in individual’s environment can contribute to psychiatric diseases, the picture is quite complicated because it also depends on personal characteristics and genetic conditions (Schmidt, 2007).

Conclusion

Psychiatric disorders are common among people of various ages. Factors leading to the development of such health conditions have a wide range of obstacles, including genetics, as well as personal and environmental causes. The role of neurotransmitters is also essential because cases when they do not work correctly can lead to certain psychological disorders such as depression or Parkinson’s disease. Among major personal factors, there are genetics, injuries, traumatic experience, substance abuse, and issues during gestation or birth. Poverty, poor nutrition, exposure to toxins, chronic stressful situations, and any relationship issues are the most common environmental conditions leading to such diseases. Taking into account the main causes of mental illnesses, it is important to provide specific interventions to remove certain environmental threats, which result in psychiatric diseases because such preventive actions may decrease their prevalence.

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Hepatitis A is a strain of a severe liver infectious disease, induced by the virus of hepatitis A. This type of infection is regarded as the least dangerous form among the range of other hepatitis viruses as it cannot take a chronic course. Hepatitis A virus is distinguished by ubiquitous, non-uniform intensity in certain regions, and cyclicality in the long-term dynamics. It is aggravated during autumn-winter season, and predominantly involve of preschool children, adolescent and young adults. This virus is clinically manifested by syndrome of intoxication, hepatosplenomegaly and jaundice. The paper will discuss symptoms, causes, and treatment of hepatitis A virus.

Symptoms

A hepatitis A virus is an acute cyclic benign viral infection from the group of the fecal-oral hepatitis, which is accompanied by the necrosis of hepatocytes. Common gateway for the virus is the mucous membranes of the oropharynx and the small intestine. The inflammatory processes that are responsible for the formation of catarrhal syndrome, dyspepsia, and the reaction temperature are developed. The penetration of the pathogen into the blood system leads to viremia, through which it quickly reaches the liver. Patients with viral hepatitis A experience significant damage around the portal areas together with an intensive cellular infiltration and destruction of the border plate, pronounced signs of cholestasis. The antigens of the virus show high immunogenicity. The activation of the immune system and other specific processes of sensitization of lymphocytes start from the introduction of the pathogen.

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The incubation period lasts from three to four weeks. The hepatitis A virus is an acute cyclic disease and is characterized by a succession of several periods – prodromal, height (jaundice), and the period of convalescence. Prodromal stage is characterized by relatively wide diversity of first symptoms, conventionally grouped into several variants of its course. Flu (febrile, catarrhal) option in hepatitis A is the most common symptom. Usually the disease begins quite sharply with the increase in body temperature, weakness, malaise, muscle pain, development of pulmonary catarrhal symptoms (nasal congestion, sore or scratchy throat, coughs) (“Hepatitis A”). However, flu-like symptoms in most cases are accompanied by the dyspeptic disorders of varying severity. In the dyspeptic option, catarrhal symptoms are absent. Patients are concerned about the discomfort in the epigastric region, accompanies by the loss of appetite. The discomfort is characterized by dull pain in the right upper quadrant, bitterness in the mouth, belching, constipation, or loose stools. The asthenovegetative option is characterized by a number of nonspecific symptoms: general weakness, performance loss, irritability or apathy, sleeplessness or, conversely, drowsiness. Viral hepatitis A can clinically manifest itself immediately with the development of jaundice. It should be emphasized that in this term, the clinical symptomatology may be combined in various combinations. The complications after the virus are developed comparatively rare. However, if they are, they include acute inflammatory processes in the biliary tract (cholecystitis, cholangitis, dyskinesia), as well as the development of secondary infections (pneumonia, etc.) (“Hepatitis A”). Acute hepatic encephalopathy in hepatitis A is extremely rare.

Cause

The hepatitis A virus is among the most widespread intestinal infections in the world. The causative agent of this virus is RNA genomic virus Picornaviridae (Lanford et al. 11223). The virions are small and simply organized. The reservoir and source of virus is a person with any signs of disease (icteric, anicteric, asymptomatic inapparent forms). An ill person is dangerous to others starting from the second week of the period of incubation of the disease. The peak of viral shedding occurs in the first week of the illness. Chronic carriage of the virus by one individual has not been established. There are cases of human infection from chimpanzees and other monkey species. The spread of infection is associated with poor sanitation and overcrowded population. Particularly high incidence of hepatitis A is in the developing world.

The mechanism of transmission of hepatitis A is fecal-oral. Sick man ejects the virus in faeces. Then, virus enters the bodies of other people with water or food (Nainan et al. 69). This is the process of fecal-oral contamination. In most cases, children, who are infected with the virus through dirty hands, become sick with hepatitis A (“Hepatitis A”). Because of this tendency, HAV is also known as the “dirty hands” disease. There is also the possibility of sexual transmission of infection, particularly in the gay environment (Nainan et al. 70). In addition, there are cases of the contamination of this disease, described in the parenteral administration of psychotropic substances, transfusion of blood, and its products. The role of each transmission path varies in different conditions. A watercourse usually leads to the outbreaks of the disease among people, who use contaminated water, or swim in contaminated pools and lakes. Because hepatitis A can survive in water for weeks, the infection can occur after the use of various raw clams, or mussels that are collected from areas contaminated by sewage. Infected food outbreaks are most commonly associated with the contamination of food products in the enterprise by personnel with mild disease or poor personal hygiene. The contamination of fruits and berries (especially strawberries and strawberry salad) is possible in the case of their fertilization with human’s faeces. Regularly, the contact-household transmission path takes place in child homes, orphanages, or other similar institutions, especially in terms of their unsatisfactory sanitary conditions. Although this disease is typical mainly for the third-world countries with poor hygiene and sanitation, isolated cases, or outbreaks of hepatitis A disease can be traced even in the most developed countries. Natural person’s susceptibility is high. After the penetration of the infection, persistent stressful immunity is generated. Asymptomatic forms of the disease form less stressful immunity.

Treatment

To diagnose a hepatitis A, first it is necessary to create an epidemiological history of where the individual was in the last month, what he ate, and what water he drunk, whether he was in contact with infected patients, etc. Then the doctor carefully examines the patient in the daylight and looks for signs of intoxication (general condition, state of health), dyspepsia (indigestion), presence of fever (sweats, chills), jaundice (skin, tongue, eyes). The doctor usually evaluates the condition of various organs and systems by the standard technique.

After establishing the diagnosis of the disease, patient’s treatment can be performed on an outpatient basis. The patients with the severe course of the disease, with the protracted forms in the presence of severe co-morbidities, as well as decreed groups are always hospitalized. Patients are prescribed bed regime for a period of badly expressed intoxication syndromes and nutrition. The diet excludes high-melting fats, fried food, canned food, pickled production, onions, garlic, and spices. What is more, alcohol is strictly forbidden and Lacto-vegetarian food is highly recommended. In addition to the food group, vitamins C and B are added. Due to the lack of funds of causal treatment, pathogenetic treatment is carried out. To remove the intoxication, depending on its extent, excessive drinking or infusion solutions are used. For daily bowel cleansing and the suppression of the anaerobic flora, it is recommended to administer the derivatives of lactulose, which dose is picked individually. To treat cholestatic component, antispasmodics (no-spa, aminophylline), and derivatives of ursodeoxycholic acid are used.

On average, the disease lasts for about a month. The duration largely depends on the age, immune status, presence of concomitant chronic diseases, and strict implementation of the recommendations of the doctor. Some patients suffer from the chronic form of this infection. Deaths from hepatitis A are rare and occur in patients with fulminant (lightning) form of the disease. In these cases, acute liver necrosis that is accompanied by acute liver failure develops very quickly.

The main preventive measures of the virus are the provision of safe water and the creation of safe conditions. Moreover, it is important to ensure the implementation of sanitary rules that are imposed on the harvesting, storage, preparation, and sale of food products. It is crucial to provide the proper anti-epidemic regime in the organized children and adult teams and communities. Additional measures should be also directed to the active search for sources of infection, increased disinfection modes, and objective health education of children and adults. During the increasing preseason incidence, immunoglobulin prevention is effective. Currently, a vaccine against hepatitis A is provided as another specific preventive mean (“Hepatitis A”). It provides a rapid, but short-term protection. Vaccine creates active immunity, accompanied by a long loop of its own antibodies. However, widespread vaccination against hepatitis A is restrained by its relatively high cost. Nonetheless, the harm that is caused by hepatitis A significantly exceeds the cost of the vaccination. Taking into the account the high susceptibility of children and the fact that they are the main sources of infection for adults, promising direction is the preventive vaccination against the virus among young children and schoolchildren.

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Conclusion

Viral A hepatitis (Botkin’s disease, a dirty hands disease, jaundice) is an acute infectious disease with fecal – oral mechanism of transmission, mainly affecting the liver and the digestive tract. Hepatitis A is a disease of viral origin, which can have mild or severe form. The infection of humans occurs when consuming infected food and water, and sometimes through the contact-household way. The virus is associated mainly with the lack of clean water and poor sanitation. Improved sanitary conditions and Hepatitis A preventive vaccination are the most effective ways to combat the disease.