Category: Therapy

Women undergoing breast reconstruction experience pain after the surgical process (Consentino, 2009). Several preventive measures have been tried to remedy this situation. Stress and depression are other symptoms related to the diagnosis and treatment of the medical complication. Strategies to help women cope with such plastic surgery issues are therefore being developed and implemented. Research has been conducted on how art therapy can intervene in these predicaments.

A research study focusing on the coping of patients was done on women of different ages and social backgrounds. 41 patients were divided into two groups of individual sessions and a control group (Magnusson, Oster, Svensk, Thyme, et al, 2006). The therapy allowed them to reflect and express thoughts about how they perceive themselves and strived to reduce stress among patients and improve their body image. The first art therapy session involved drawing visual images that are analogous to represent different feelings. The second session involved drawing of personal body image outline to express different feelings in their body through shape and color. The women followed their own choices with relevant application of individual art therapy in the third and fourth sessions. In the final session, they created an image as a summary of the creative journey.

The coping mechanisms of the patients significantly increased for those who underwent art therapy. The healing process depends on how one experiences her body and her relationship with others. Social and material resources, positive beliefs, and energy are part of the applicable strategies. Breasts symbolize motherhood and sexuality, and their relation to femininity frequently coerces victims to the surgery room. The identity and relationship that they maintain are usually influenced by the media and medical reports (Magnusson, Oster, Svensk, Thyme, et al, 2006). In the study, viewing ones body positively helped in coping with breast reconstruction.

The second study which involved 86 women aimed to describe the relationship between anxiety and pain after surgery. It involved research that gives evidence on how different forms of therapies of breast reconstruction and mastectomies help reduce acute and chronic pain in victims (Lopez, Kodumudi, Naravan, Schreck, & Vadivel, 2008). The studies indicate that the surgical process has different effects depending on the physical and mental distinctiveness of the client.

The pain that women go through after a mastectomy and breast reconstruction occasionally produces negative impacts on the physical and psychological procedures of the body. A variety of everyday life activities such as employment, sex, and socializing are therefore affected (Lopez, Kodumudi, Naravan, Schreck, & Vadivel, 2008). Different forms of alternative medicine proved beneficial in eliminating or reducing the pain related to the surgical procedure.

Art therapy is one of the mind-body strategies under CAM. The mind is manipulated to influence how the body behaves to enhance healing. The results of the reports prove that it increases cohesion, decreases depression and stress, and improves general well-being. The experiences of women and their emotions are part of art therapy, which enables them to focus on specific issues of concern. This treatment method employs color, paper, and images to symbolically express the intensity of feelings (Cosentino, 2009). The responses of the client to the created images reflect an individuals beliefs and concerns.

The use of creative expression can be successfully integrated into the nursing practice to promote the physical and emotional treatment process. Particular techniques will help me understand my patients feelings, develop their social skills, and reduce anxiety before entering the surgery room (Rubin, 2001). Patients would be subjected to an unstructured approach, where they would choose colors and materials of their choice, allowing comatose material to appear. They would then draw pictures that describe their perception and relationship to society. The clients may also be clustered and work together to create images to promote conversations that will explore coping strategies.

Art therapy is based on a theory of innovation and healing arising from one source (Rubin, 2001). It is not merely a way to relax or practice doing sketches, rather it provides a sensory system in the body which teaches patients to use images and objects to explain their emotions to society. A proper session will result in a greater understanding of self, which will ensure a faster healing process.

References

Cosentino, B. (2009). Art therapy: how creative expression can heal. The Doctors of USC. Web.

Lopez, J., Kodumudi, G., Naravan, D., Schreck, M., & Vadivel, N. (2008). Invited commentary: pain after mastectomy and breast reconstruction. Walden University Library.

Magnusson, E., Oster, I., Svensk, A., Thyme, K., et al. (2006). Art therapy improves coping resources: a randomized controlled study among women with breast cancer. Walden University. Web.

Rubin, J. (2001). Approaches to art therapy: theory and technique (2). New York: Psychology press.

Significance and Background

Healthcare Problem

Pain is an unpleasant sensation that is linked to illness or potential tissue damage. Acute pain occurs in response to inflammatory responses, thermal, chemical, or mechanical impetus, surgical procedures, or physical injury and often subsides within a few days or weeks. Conversely, chronic pain persists for at least three months notwithstanding treatment (Wren et al., 2019). Measuring and treating pain in pediatric patients are obfuscated by the inability to construe pain accurately, which is associated with poor communication between medical personnel and patients. Furthermore, opioid therapy, which is the mainstream pain treatment has numerous adverse effects. Consequently, the application of complementary and alternative medicine (CAM) is desirable. CAM encompasses unconventional treatments, for example, acupuncture, homeopathy, massage, yoga, osteopathic medicine, dietary supplements and adjustments, herbal medicine, music among others (McClafferty et al., 2017). This paper investigates the application of CAM treatments to alleviate pain in children.

Significance

Chronic pain is documented in 15 to 25% of children and is associated with hospital emergency room visits and reduced quality of life (Brown et al., 2017). Even though opioids are beneficial in pain management, they cause numerous side effects such as changes in breathing, gastrointestinal disturbances, and cognitive dysfunction, physical tolerance, increased pain sensation, dependence, and addiction (Timmerman et al., 2019). Therefore, the use of CAM can mitigate some of these side effects while managing pain effectively.

Current Healthcare Practices

Current pain management practices among children follow the stepwise approach recommended by the World Health Organization (Kahsay, 2017). The first-line treatment for mild to moderate pain is non-opioids such as acetaminophen (paracetamol), which is preferred because of relatively fewer side effects. The next line of drugs is non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, diclofenac, ketoprofen, and acetylsalicylic acid. As the magnitude and severity of pain increases, opioids such as morphine, codeine, tramadol, and fentanyl are considered.

Impact of the Problem on the Organization and Patients

In the practice setting, many pediatric patients experience acute and chronic pain as a result of various health conditions. Numerous cases of side effects of pain medications have been documented. Underinsured patients with chronic health conditions have reported poor quality of life due to the inability to afford pain medications. Furthermore, increases in opioid diversion, over-prescription, and misuse have been reported. Implementing CAM therapies will curtail misconduct related to analgesics, minimize undesirable upshots, and enhance patient outcomes in children experiencing pain.

Search Strategy

A literature search was performed on the institutions library database to find peer-reviewed publications related to the healthcare problem. The key search terms used were pain management, complementary and alternative medicine, standard care, and pediatric patients. The search was limited to articles published within the last five years. Abstracts of retrieved items were read to determine their relevance to the problem. A total of seven articles were selected for further review. They included five research and two non-research articles. A summary of all the seven publications is provided in the evidence matrix.

Of the two research evidence sources, the first article by Bertrand et al. (2019) examined the effect of foot reflexology in the management of relentless pain in children. The authors conducted a prospective study in which all children experiencing pain received the intervention. The effectiveness of the intermediation was determined by pain assessment using the visual analog scale (VAS). The key finding was that foot reflexology resulted in a significant reduction in pain scores, indicating the effectiveness of the approach. In a separate study, Marom et al. (2016) conducted a systematic review of the literature to determine beneficial CAM approaches to manage pain associated with otitis media in children. The use of CAM in otitis media incorporated methods such as phytotherapy, acupuncture, ear candling, homeopathy, vitamin D supplementation, herbal medicine, xylitol, osteopathy, chiropractic care, and probiotics.

The non-research evidence sources that were considered included a clinical guide for clinicians in pediatric pain management. McClafferty et al. (2017) acknowledge the use of CAM and provide relevant information regarding common interventions, their application, educational resources, and communication tactics for the discussion of CAM approaches between patients and clinicians. Vohra et al. (2017) proposed a clinical trial to evaluate the cost-effectiveness of CAM in inpatient settings. The proposed pediatric divisions in which the study would be conducted include oncology, cardiology, and general medicine. Findings from this study would guide the use of CAM in hospitals.

PICO Question

In pediatric patients experiencing pain, will the use of CAM compared to usual care lead to a reduction in pain?

Evidence Matrix

Recommended Practice Change

Healthcare practitioners should incorporate CAM into the routine management of acute and chronic pain in pediatric patients. The reviewed studies have demonstrated the benefits of CAM in the alleviation of pain. For instance, foot reflexology has shown immense benefits in chronic pain alleviation in children, teenagers, and young adults aged 25 years or below (Bertrand et al., 2019). Acupuncture shows promise in pain relief for patients with sickle cell disease (Mahmood et al., 2020), whereas hypnotherapy improves procedural pain in cancer (Jong et al., 2019). For children aged 5 years and older, music therapy eases anxiety and pain (van der Heijden et al., 2018). Additional CAM strategies that can be considered include probiotics, herbal remedies, acupuncture, ear candling, homeopathy, vitamin D supplementation, herbal medicine, xylitol, osteopathy, and chiropractic care (Marom et al., 2016). However, precise interventions should be chosen based on available supporting evidence.

Implementing the Practice Change

Key Stakeholders

The three key stakeholders in the implementation of the practice change are the nurse, caregiver, and primary physician. The primary physician is tasked with evaluating the patents pain and making pertinent referrals to pain specialists. The role of the nurse is to assess the patients pain, interpret it, administer the intervention in clinical settings, and evaluate the efficacy of the intermediation. In contrast, the role of the caregiver is to oversee or implement the recommended CAM intervention when the patient is away from the hospital. These three stakeholders would be involved in determining and working towards precise treatment goals for the patient.

Barriers

One barrier to the implementation of CAM therapies is patient and caregiver doubts regarding the effectiveness of CAM, which results in non-adherence and poor clinical outcomes. A second barrier is poor communication and knowledge gaps, which may bring about unintended consequences. For instance, the concurrent use of certain dietary supplements with pharmacological agents may result in adverse reactions. Patients may not open up about the use of CAM therapies at home.

Strategies to Overcome the Barriers

Doubts concerning the effectiveness of CAM therapies can be erased through patient education, which may also involve the caregivers. The nurse should provide a brief rationale for the proposed CAM methods to the patients to encourage compliance. Conversely, clinicians need to find out about supplement use, include it in the patients medical records, and find any potential drug interactions. Encouraging open communication about any CAM practice that the patient engages in can minimize the likelihood of adverse reactions.

An Indicator to Measure the Outcome

The primary indicator to measure the outcome of the intervention is pain. The visual analog scale (VAS) will be used for this measurement. This tool uses an unmarked line that is 100 millimeters long with the words no pain and unbearable pain written on the left and right ends, respectively (Bendinger & Plunkett, 2016). During the assessment, the patient is required to mark a point along the scale that corresponds to the extent of their pain.

References

Bendinger, T., & Plunkett, N. (2016). Measurement in pain medicine. BJA Education, 16(9), 310-315.

Bertrand, A., Mauger-Vauglin, C. E., Martin, S., Goy, F., Delafosse, C., & Marec-Berard, P. (2019). Evaluation of efficacy and feasibility of foot reflexology in children experiencing chronic or persistent pain. Bulletin du Cancer, 106(12), 1073-1079. Web.

Brown, M. L., Rojas, E., & Gouda, S. (2017). A mind-body approach to pediatric pain management. Children, 4(6), 1-13.

Jong, M. C., Boers, I., van Wietmarschen, H., Busch, M., Naafs, M. C., Kaspers, G. J., & Tissing, W. J. (2019). Development of an evidence-based decision aid on complementary and alternative medicine (CAM) and pain for parents of children with cancer. Supportive Care in Cancer, 1-15.

Kahsay, H. (2017). Assessment and treatment of pain in pediatric patients. Current Pediatric Research, 21(1), 148-157.

Mahmood, L. A., Reece-Stremtan, S., Idiokitas, R., Martin, B., Margulies, S., Hardy, S. J., Bost, J.E. & Darbari, D. S. (2020). Acupuncture for pain management in children with sickle cell disease. Complementary Therapies in Medicine, 49, 102287.

Marom, T., Marchisio, P., Tamir, S. O., Torretta, S., Gavriel, H., & Esposito, S. (2016). Complementary and alternative medicine treatment options for otitis media: a systematic review. Medicine, 95(6), 1-9.

McClafferty, H., Vohra, S., Bailey, M., Brown, M., Esparham, A., Gerstbacher, D., Golianu, B., Niemi, A.K., Sibinga, E., Weydert, J., & Yeh, A. M. (2017). Pediatric integrative medicine. Pediatrics, 140(3), 1-23. Web.

Timmerman, L., Stronks, D. L., & Huygen, F. J. (2019). The relation between patients beliefs about pain medication, medication adherence, and treatment outcome in chronic pain patients: A prospective study. The Clinical Journal of Pain, 35(12), 941-947. Web.

Van der Heijden, M. J., Jeekel, J., Rode, H., Cox, S., van Rosmalen, J., Hunink, M. G., & van Dijk, M. (2018). Can live music therapy reduce distress and pain in children with burns after wound care procedures? A randomized controlled trial. Burns, 44(4), 823-833. Web.

Vohra, S., Schlegelmilch, M., Jou, H., Hartfield, D., Mayan, M., Ohinmaa, A., Wilson, B., Spavor, M., & Grundy, P. (2017). Comparative effectiveness of pediatric integrative medicine as an adjunct to usual care for pediatric inpatients of a North American tertiary care centre: A study protocol for a pragmatic cluster controlled trial. Contemporary Clinical Trials Communications, 5, 12-18.

Wren, A. A., Ross, A. C., DSouza, G., Almgren, C., Feinstein, A., Marshall, A., & Golianu, B. (2019). Multidisciplinary pain management for pediatric patients with acute and chronic pain: A foundational treatment approach when prescribing opioids. Children, 6(2), 1-22. Web.

Introduction

The term chemical dependency refers to a psychological and physiological process that entails the use of alcohol and other drugs in order to achieve the desired effect and feeling. Patients with chemical dependency exhibit such symptoms as addiction whereby the need for the drug re-use does not go away even if there use causes side effects. Chemical dependency is largely influenced by genetic, psychosocial and environmental factors (Carroll, 2000).

The disease is progressive in nature and sometimes it can lead to death. Chemical dependency can be managed through behavioral therapy whereby a patient is counseled with the intention of ending this condition. Behavioral therapy can be either individualized or undertaken in a group. This research gives the benefits as well as shortcomings of individualized and group therapy about treatment of chemical dependency. The preferred method of treating this condition will also be given.

Individual approach

Individual therapy involves concentration of one individual at a time for the management chemical dependency. In individual approach, one psychotherapist meets with a client for a specified period within a given timeframe whereby the therapists counsels the patient with the intention of changing his behavior (Carroll, 2000). Patients have the therapists full attention during the session.

Confidentiality is highly emphasized in the individualized model thereby helping the patient feel more secure and safe. The individual format is helpful as a patient engages in multiple sessions and is therefore able to identify key issues that are likely to be the cause of chemical dependency. This evaluation may not occur in group therapy (Carroll, 2000).

Patients who are reserved and self-centered benefit highly from individualized therapy because of confidentiality. Additionally, individualized treatment is also preferred as the therapist is able to fully concentrate on a particular patients problems and address them in totality unlike in group therapy where individual problems may fail to be addressed fully.

Group therapy

Group therapy refers to using a group of people with or without similar medical presentation in the treatment of particular illnesses. Group therapy also is a support group where individuals with similar medical condition come together and share their experiences and challenges with the disease process (Capuzzi & Staufer, 2008). In group therapy, the therapist can also include individuals who have already gone through the same problem to act like a source for inspiration for the starters. In the use of group therapy, the therapist hopes to instill in the patients the fact that human beings social and should therefore be collectively involved in devising solutions to problems that they confront (Capuzzi & Staufer, 2008).

The fact that patients discover there are several people suffering from a particular condition makes it easy for them to embrace the condition and devise solutions amicably. This makes group therapy in drug and chemical dependency a strong and powerful therapeutic tool (Engs, 1990). The group therapy lays its focus on peer support. Discussion group and exchange of ideas from peers, social skills and reduction of feeling of isolation and gives hope to participants.

Additionally, group therapy offers a psycho- education, cognitive behavior modification to patients. Such strategies aid in the modification of ones behavior and equip the patient with knowledge that helps the patient embrace a better lifestyle free from chemical dependency (Capuzzi & Staufer, 2008). Group therapies encompass various mechanisms with the intention of developing the patients skills. For instance, skills development groups work to develop the skills that are necessary for the individual to break off the bonds of addictions (Bestha & Madaan, 2006). Cognitive behavioral groups assist a patient change the thinking pattern in order to achieve ways to stop addictions (Capuzzi & Staufer, 2008).

Group therapy also makes it possible for patients to join support groups where they are motivated to stop the addictions from individuals who were earlier on involved in the vice. Psychotherapy groups are also incorporated in group therapy with the intention of molding a patients approach to life. These groups assist a patient to rethink about their pastas well as on the future after rehabilitation. It enables them think of the past and events that lead to addiction.

Group therapy enables patients to give their personal submission on how to go about with life challenges through provision of positive support as well as pressure. According to Capuzzi & Staufer (2008), group therapy, from the very beginning, elicits a commitment by all the group members to attend and to recognize that failure to attend, to be on time, and to treat group time as special disappoints the group and reduces its effectiveness.

Group therapy ends the sense of isolation that people with substance abuse tend to have. This makes an individual feel he is not the only one, this will aid quick recovery and enhances the feeling of security and enables the individuals to open up and share their challenges. It enables individuals to learn on how to cope with their problems through experiences of other people (Bestha & Madaan, 2006).

They see other go over it while in the rehabilitation center hence giving them hope. In group therapy there is room for feedback thus the therapist is able to modify faulty concepts as well as assess the level of recovery of an individual (Capuzzi & Staufer, 2008). Groups also help one another to sharpen social skills that individual needs in coping with the challenges of life.

According to Bestha & Madaan, (2006) groups can confront an individual who reverts to drug abuse, especially because of the common bond that has already been established between the group members. From group work, a single treatment provides solution to almost all members and the society at large (Capuzzi & Staufer, 2008). For instance, treatment of five individuals will make five people who will talk against the problem out in the community unlike the individual approach. It is also a source of hope because if an individual has seen many people go through the process, he also develops energy and inspiration to keep him fighting.

Conclusion

Individualized and group therapies achieve different responses during the treatment of chemical therapy. However, group therapy has more advantages in the management of chemical dependency especially because patients understand other people are struggling with the condition and want to end the dependency (Bestha & Madaan, 2006). Management by individualized therapy results to patients experiencing sense of insecurity, loneliness, and the feeling of being unwanted and may therefore not fully cooperate with the therapist. Group therapy helps fasten the recovery of the patients from the rehabilitation center as compared to individual therapy since it encourages socialization and sharing problems.

References

Bestha, D. & Madaan, S. (2006). Textbook of Psychiatry/Psychotherapy for Medical Students New York, U.S.A: Sage publishers.

Capuzzi, D. & Staufer, M. (2008). Foundations of Addictions counseling. New York, U.S.A: Foundations of Addictions Counseling.

Carroll, K. (2000). A Cognitive-behavioral approach: Treating cocaine addiction. London, UK: National Institutes of Health.

Engs, R. (1990). Controversies in the Addictions Field. New York, U.S.A: Kendall Hunt Pub. Company.

The Zika virus (ZIKV) is a mosquito-borne virus in the member of the Flaviviridae family, genus Flavivirus. The virus was first found in 1947 in the blood of a monkey in Uganda’s Zika Forest giving the virus its name. There are two lineages of the Zika virus, African and Asia. The Asian strain caused outbreaks in Micronesia in 20019 and French Polynesia in 2013-2014. (White, Wollebo, David Beckham, Tyler, & Khalili, 2016) Zika was transmitted originally in a sylvatic cycle between monkeys and Aedes mosquitos in Africa but it was spread by the reciprocal infection of man and mosquitos. It can also be spread by sexual transmission or by blood transfusions. (White et al., 2016) The first direct evidence of the presence ZIKV in the Asian continent and the first proof of its transmission by an urban vector as found through the isolation of the virus from A. aegypto mosquitos in Malaysia in 1966. It wasn’t until 2015 that the virus really got national attention due to the increased number of microcephaly in neo-natal cases in Latin America. ((Basak et al., 2019) Some of the symptoms of ZIKV include a rash, itching all over the body, headache, joint pain with possible swelling, muscle pain, red eyes, lower back pain and pain behind the eyes. Even though ZIKV itself can be dangerous, the association that the virus has with microcephaly in pregnant women and Guillain-Barre syndrome makes research more urgent than ever.

ZIKV has a genome about 11 kb in length, made up of single stranded, positive sense, RNA that encodes 3 structural and 7 nonstructural proteins expressed as single polyprotein undergoing cleavage. The virions are enveloped and icosahedral. The genome of the Zika virus replicates in the cytoplasm of infected host cells. Zika includes several parts, including the capsid protein about 13 kDa in length, a lipid bilayer containing protein M and envelope protein E. The genomic RNA lacks a poly-A tail at the 3’ end. (White et al., 2016) The prM and envelope E protein mediate the virion attachment to and fusion with host-cell membranes. The NS proteins (non-structural proteins) have many roles that include promoting replication and sometimes even evading the host innate immune response. When infected, the virus induces perinuclear membrane arrangements to create an environment for replication called replication factories. Some of the changes that happen are the appearance of convoluted membranes, formation of vesicles that have been invaginated (clustered double-membrane vesicle packets) and even cellular cytoskeleton changes. It replicates via intermediary synthesis of negative-sense antigenomes. ZIKV is has been found to infect multiple cells types in the brain such as glial cells, neurons, and neuronal stem cells. (Liu et al., 2018) The genome contains so many crucial portions for the virus to replicate and infect but the way that it does this can be complex. (Basak et al., 2019)

Flavivirus bind to surface of target cells by interactions with viral surface glycoproteins and cellular cell surface receptors. The virions undergo receptor-mediated endocytosis and are internalized into clathrin-coated pits. (White et al., 2016) Steps of replication happen through the production of double-stranded RNA intermediates. Once assembled in the ER, progeny virus particles form a multivescular body-like structure and exit into the cytoplasm through a channel most likely through abscission from [membrane or a pore on the multivesicular body. Particle budding also is observed in other areas of the ER and away from Vp suggesting mature virions are trafficked through a secretory pathway for release from cell. (Liu et al., 2018) ZIKV uses the host cytoplasmic membrane for replication of its genome and the host attempts to control the infection with several responses such as interferon release, unfolded protein/ER response, autophagy and apoptosis. The translation of the viral proteins from the RNA happens from the long open reading frame to make a large polyprotein that is cleaved co- and post-translationally into the viral proteins and leads to replication. This replication starts with the synthesis of negative-strand RNA (template) for synthesis of copies of the positive-strand RNA. This requires several viral NS proteins. (White et al., 2016) One of the least known things about Zika is the mechanism at which flavivirus migrate to the CNS. There are three possible migration pathways currently being tested: through peripheral nerves and after mosquito bite involving retrograde transportation through axons, through the blood-brain barrier with altered permeability resulting from presence of pro-inflammatory species, and carried by immune cells known as “Trojan horse”. (de Oliveira et al., 2019). From the initial stage in Uganda, the ZIKV has many alterations. There are two major groups: one with older sequences from the African continent and another with more recent Asian, Pacific, and American sequences. (Basak et al., 2019) The way the ZIKV attaches, replicates and exits has many different parts to it and one of the most interesting is how ZIKV interacts with the immune system. (White et al., 2016)

ZIKV can evade the immune system by regulating the type I interferon response with its encoded NS5 protein. Compared to other flaviviruses, ZIKV sexual transmission makes it unique and gives the potential for human-to-human transmission. The most common is male to female which suggests a difference between the sexes. In females, a strong response inhibits the virus to control the infection. In males, however, the response correlates with viral persistence. (Arévalo Romero et al., 2019) One approach to study the pathogenesis has been to infect neonatal mice since adult wild-type immunocompetent mice are resistant to ZIKV infection. Infected neonatal wild-type mice showed infiltration of T cells into the central nervous system, very similar to models of neuro-invasive flavivirus infection. Mouse models have also shown that the virus can accumulate in the blood, spleen, brain, spinal cord, kidney, and eye. Studies in pregnant female mice have shown that ZIKV infects trophoblasts and fetal endothelial cells of the placenta and then crosses the placenta to infect the fetal head. It is also important to note that another study also found that ZIKV RNA persisted in saliva and seminal fluids for at least 3 weeks after the virus was not found in peripheral blood. Animal and human studies of ZIKV pathogenesis have also shown broad tissue and cell tropism for ZIKV as well as the ability to cause severe organ disease and placental and congenital infection. (Miner & Diamond, 2017) It’s important to note that these mechanisms are vital to production of vaccines.

As of now there are no vaccines available for Zika but there are several vaccines in development. It is reported that there are about 14 vaccines currently under development at Clinical Phase Trial I and 2 vaccines have moved to Clinical Phase Trial II. They are either DNA-based vaccines or inactivated whole Zika Virus vaccines. There are also two recombinant viral vectors, a peptide vaccine based on mosquito salivary proteins and another that utilizes prM-E mRNA transcript of ZIKV. One of the biggest challenges in administering Zika vaccines is the naturally phenomenon called antibody dependent enhancement or ADE. This phenomenon is reported in cases of secondary Dengue fever because of Zika’s close relation to Dengue, someone with a Zika vaccination might be severely affected by ADE if they are naturally or otherwise infected with ZIKV. (Basak et al., 2019) Currently in the Garg and Joshi lab they have developed virus-like particles that act as reporter genes with fluorescent tag so that the actual live virus doesn’t have to be tested. The lab has been the first to generate a stable cell line that secretes Zika CprME VLP (virus-like particles) by natural NS2B-3 cleavage which show incorporation of capsid in CprME VLPs and complete protection. This is a huge breakthrough for the vaccine platform and is safe for use in pregnant women. (Garg, Mehmetoglu-Gurbuz, Ruddy, & Joshi, 2019) There are also several carbohydrate compounds being tested to see if they can lower the infectivity of ZIKV as well as timepoint experiments being used to see if those compounds have the capability of lowering infectivity even after exposure to the virus. Several compounds have already shown promising results and will be further tested for the rest of the year. Another new approach is the use of peptide vaccines. Epitopes from conserved regions among proteins with high solvent accessibility are selected for the antiviral vaccine. These epitopes are then tested for population HLA sensitivity and autoimmune risks. At the end rank-based epitopes are chosen to more analysis such as efficacy, longevity, range, side effects, etc. There have been many articles pointing to suitable and effective epitopes found in the capsid, envelope, NS2A, NS3, NS4B, and NS5 proteins of the virus. (Basak et al., 2019) There are a few drug targets that have the potential to make an impact on the fight against ZIKV.

As discussed previously, viral glycoproteins play an important role for virus infection and replication therefore envelope glycoprotein inhibitors are well researched for anti-ZIKV activity. There are a few inhibitors that have also had promising results. Some of these include protease inhibitors, NS3 helicase inhibitors (bind to RNA and ATP binding sites), NS4B inhibitors (even though this research faces many challenges because of poor ADME properties of the inhibitors), NS5 methyltransferase inhibitors (Sinefungin is one such example), NS5 polymerase inhibitors, and non-nucleoside RNA polymerase inhibitors. (Basak et al., 2019) The virus itself can be lethal but other complications can arise from being infected.

One of the most unique aspects of ZIKV is the association that it has with microcephaly in pregnant women and Guillain-Barre syndrome (GBS). GBS is a potentially life-threatening peripheral nerve disease characterized by a very fast onset of bilateral weakness that progresses to paralysis. It could also be accompanied by sensory symptoms. It occurs about 1-3 weeks after ZIKV infection and is believed to trigger a pathogen-specific immune response that interacts with peripheral nervous system antigens. (Dhiman, Abraham, & Griffin, 2019) Typically GBS is a rare neurological disorder and the exact cause (when not infected with ZIKV) is unknown. Currently there is no known cure for GBS but some therapies can help to lessen the seriousness and shorten the recovery time. (NIAMS, 2016) Microcephaly is a condition where the circumference of the head is smaller than normal because the brain stops developing properly or has stop growing completely. There is no treatment for microcephaly but there are ways to lower the impact of the deformities and neurological handicaps. There are early childhood programs such as physical, speech and occupational therapies for therapists to increase abilities and minimize problems. (NIAMS, 2016) Neuroinflammation has been proposed as one of the key factors that contribute to ZIKV-related microcephaly especially those that are mediated by glial cells. (de Oliveira et al., 2019) Pregnant women should be questioned about potential exposure before and during pregnancy so that tests can be done. Placental testing can be used if diagnosis is unclear. Serial ultrasounds are performed to look for congenital infection and then every 4 weeks. (Leeper & Lutzkanin, 2018) Someone who could have been infected has to take precautions and inform doctors so that they can be prepared and have the possibility to lessen or manage symptoms.

While treatment and vaccines haven’t yet been yet completed or approved, the emergence of such a unique virus has pushed the science community to find either a vaccine or a treatment for this virus. While the virus had been around for a number of years this association that was finally made with microcephaly and GBS gave the science community a push into finding a way to combat it. With the numbers in Latin America swiftly rising and the virus reaching more places than ever before, we have to use all our resources. The uniqueness of ZIKV not only in structure but the type of cells that are affected can lead to not only death but also pregnancy abnormalities or negative effects on the nervous system. In the coming years as technology advances and as we continue to do research, we are very close to finding a treatment or a vaccine that could help us eliminate this potentially devastating virus.

If you had the flu, you should know how bad it can make you feel. A stuffy nose, sore throat, and fever can put you out of work for a couple of days. Fortunately, there is a protection against this dangerous disease: a flu vaccine. Each year, this shot contains particles from the four strains of influenza most likely to be common that coming flu season. It is the strains that determine the flu shot’s effectiveness. Once those are put into the body, the immune system generates antibodies that protect you from the flu should you be exposed to it. While no vaccine will protect you all the time, the flu shot lowers your odds of catching this virus. The trouble is, only about half of the people get immunized each year. Experts believe that the myths about the flu shot are partly to blame for the low vaccination rates. Here are some reasons not to get the flu shot.

Certain vaccinations can cause some bad reactions, or you might feel sick after being vaccinated. A bad reaction to the vaccine usually comes in the form of difficulty breathing, swelling of the eyes or lips, and fever. It is not common to experience these side effects, but it’s important to seek medical attention immediately if you notice any. The most common side effects are pain around the where the needle was injected, and sometimes it goes away on its own.

Yes, the flu shot may sometimes be painful and there is a chance it might not work, but the rewards almost always outweigh the risks. Some people, such as very young infants or those who have a bad history of reactions to flu vaccines, should not get the shot. Before we discuss the flu shot we should know how we can get the flu and how to protect ourselves from the flu can be very contagious—this means it can spread to multiple people, often through the air. You can pass on the cold before you feel sick. You are sick for several days after you get the flu. You can catch the flu when someone near you coughs or sneezes into the air. Or, if you touch something the cold is on, like for example a doorknob, and then touch it all over your face then you could catch the flu. The flu virus can live everywhere like a book for as long as it wants. This is why we should wash our hands often when we are around someone who is sick just so we catch it. We must wash them before eating or touching our eyes, nose, or mouth. If you can, stay away from sick people. That will help stop the flu from spreading.

Vaccines have been proclaimed by many people as one of the miracles of modern medicine. Vaccines are credited with saving thousands of lives and wiping out many contagious diseases. Recently, there has been a tremendous debate about whether annual influenza vaccines should be mandatory. Influenza vaccines should be voluntary because people have the right to examine data on vaccinations and make their own informed decisions. Although people should have the freedom to choose to be vaccinated, the public needs to be educated about the personal, economic, and social benefits of receiving the influenza vaccine.

If you had been born in the U.S. around the year 1900s, the three leading causes of death were infectious diseases, such as pneumonia and flu, tuberculosis, and gastrointestinal infections. The influence of such diseases exponentially shortened human life expectancy during that time period. Approaching the year 2010, the leading cause of death ameliorates to chronic diseases like cancer, heart disease, and stroke. For such advancement in the world, the medical field sheds light on improved sanitation practices and medical advances. For instance, vaccines were implemented for a substantial reduction in the impact of infectious diseases and increased life expectancy.

In Mercury, Vaccines, and Autism One Controversy, Three Histories written by Jeffrey P. Baker, MD, PhD, discusses the argument regarding the usage of dangerous components of vaccine manufacturing: mercury, which contains thimerosal as a preservative that affects childhood vaccines. The article examines the origins of the thimerosal controversy and explores how vaccine preservatives, mercury poisoning, and Austin are in relation to one another. This article presents the issue surrounding vaccination in children and how it can potentially affect their lives. Further research is conducted to deduce the advantages and disadvantages of vaccines to investigate the controversy. Other academic research will also be utilized to conduct an investigation on the issue revolving around the statement that vaccines cause autism in healthy children.

When foreign microbes invade the immune system, the immune system stimulates a series of responses in an attempt to identify and extract them from our bodies. The signs that the immune response is functioning are coughing, sneezing, and inflammation. These innate immune responses also trigger the second line of defense called adaptive immunity. The body takes time to learn how to respond to pathogens, but despite this immediate response, there is still risk involved with the defense. When the body is too weak or young to fight back, the individual might face serious risks if the pathogen is particularly severe. This is where vaccines come in.

The vaccine is a suspension of microorganisms that induces antibody production to protect against disease. It helps your body fight off harmful diseases by inducing our immunity to raise the infection in our body through the microorganisms. The sickening germs called pathogens and antigens will attack the immune system so the human body can be familiar with them and prevent future infections (Lambert & Siegrist, 1997). This prepares the leukocytes, white blood cells, for “eating” the bacteria in a process called phagocytosis.

Scientists use vaccines to match the body’s adaptive immune system without exposing humans to the maximum strength of the disease. This has resulted in numerous vaccines that function differently. The first type of vaccine is the inactivated vaccine, in which the microorganisms are killed and present no risk of getting the disease. For instance, Hepatitis A, and rabies are protected through the injection of inactivated vaccines to get ongoing immunity against diseases (Djurisic, Jakobsen, Peterson, Kenfelt, Klingenberg, & Gludd, 2018). The second type of vaccine is live attenuated. It contains DNA mutations that have accumulated during long-term cell culture but there is a risk of getting the disease. For example, the MMR vaccine is a live attenuated vaccine because the microorganisms are not totally killed, which can be revised to a living pathogen causing infection in your body as a possibility. The third type of vaccine is called the subunit vaccine. These vaccines are used on specific germs and the microorganisms that use adjuvants will increase the effectiveness of the vaccine. Subunit vaccines are safer than attenuated vaccines, and they can be used on people with weakened immune systems and chronic health problems (Plotkin, Robinson, Cunningham, Iqbal, & Larsen, 2017). The limitation of these vaccines is that it requires boosters, multiple doses, for protection. For example, Hepatitis B, shingles, and Haemophilus influenzae type b. The last type of vaccine is the toxoid vaccine. Toxins are taken from microorganisms that cause disease but exclude the toxicity part which turns into inactivated toxins. The toxins are treated with formaldehyde and a high-temperature 6t that turns toxin and toxoid. Toxoid vaccines protect against diphtheria and tetanus.

Vaccine manufacture and composition are complex. The safety of the individual components and the vaccine itself is tightly regulated to maximize safety. The components that are in a vaccine are antigens, adjuvants, and excipients (Rappuilo, 2014).

All vaccines contain antigen that activates the immune response system. The adjuvant is then added to help retain the active antigen and attract inflammatory factors and immune system cells to the injection site to improve the immune response to the vaccine. “Some vaccines contain a tiny amount of aluminum salts, such as aluminum hydroxide, aluminum phosphate, and potassium aluminum sulfate, to act as an adjuvant” (Rappuilo, 2014).

Aluminum is prevalent in vaccines because it is the third most common element present in the earth’s crust and found in soil (quote). We are also born with aluminum in our body and we continue to collect the element through oral ingestion of food and drinks throughout our lifetime. However, only a small amount of aluminum enters our body and the rest comes out in feces. After years of aluminum usage in vaccines, there is no evidence that aluminum in vaccines causes any long-term health issues.

The excipients are the substances in the finished product of vaccines, other than the active ingredients, in order to maintain the quality of the vaccine. There are preservatives, antibiotics, stabilizers, buffers, surfactants, solvents, residuals, and diluents in these vaccines (quotes). Within the components of the excipients, the preservatives are the relevant factor that should be discussed.

The preservatives used in vaccines are 2-phenoxyethanol (C8H10O2), phenol (C6H5OH), and thimerosal (C9H9HgNaO2S). The usage of 2-phenoxyethanol is used in a wide range of products, such as baby care products, eye and ear drops, and vaccines (quote). This compound can be removed from the body through exhaling, urination, and it is not toxic to humans. Phenol is used to keep bacteria from growing and contaminating the product. Thimerosal is a mercury compound used in some vaccines. It is used to prevent the growth of dangerous microbes. The presence of mercy is stirring up a controversy promoted by the anti-vaccination activists claiming that vaccination causes autism and have asserted that mercury in thimerosal is the cause.

Vaccine saves lives. An effective vaccine should protect an individual against any infectious diseases and other complications. In the short term, it should reduce major health problems, such as tissue damage and death. In the long term, an individual should be prevented from the gradual development of cancer. For example, viruses are known to cause cancer. However, subunit Hepatitis B vaccines and human papillomavirus (HPV) are available to prevent possible long-term liver cancer and damage. In addition, adults who had chickenpox in their childhood could be given a chickenpox vaccine to strengthen their immunity, hence reducing their future risk of developing shingles. Aside from having short and long-term protections for the individuals, a vaccinated person can benefit the community by offering indirect protection for people who are susceptible to diseases. Vaccination makes others less vulnerable to coming into contact with others who are carrying the pathogen. For instance, with a highly infectious disease like measles, it is adequate when more than 95% of the population is vaccinated to achieve sufficient herd immunity to stop transmission (quote). With vaccines, it can control and eliminate diseases.

When unvaccinated travelers or other species as a pathogen carrier, vaccinated herds can be protected from transmission of unvaccinated carriers. Also, vaccination can bring economic benefits because the quality of life increases when people have stable health conditions. Therefore, less money will be spent to treat patients when a pandemic strikes. Vaccinating has effectively reduced the number of deaths resulting from preventable diseases to benefit the world. The decrease in disease rates is a result of vaccination, aside from sanitation or improved hygiene. As a result, vaccines protect the people you care about and increase the overall health of the world.

Highlights the impact in the United States of immunization against nine vaccine-preventable diseases. All of the diseases have been reduced by more than 90% in the 2016 reported cases.

There are many benefits to vaccination, but there are also potential downsides. Vaccines can cause serious and sometimes fatal side effects. According to CDC, all vaccines carry a risk of having a life-threatening allergic reaction. These allergic reactions can cause The components of vaccines might contain harmful ingredients, such as aluminum and formaldehyde. This raises the probability of an individual having an allergic reaction to the harmful ingredients and the excess aluminum and formaldehyde can cause neurological harm. There are claims that vaccines are unnatural and that natural immunity is more efficient than vaccination, but that is debatable because people are born differently, so their bodies’ chemical balances are different.

Despite the controversial claims stating that autism can be caused by vaccination, researchers have conducted a test to assess the credibility of that claim. The story of how vaccines were put into doubt as a cause of autism dates back to the 1990s. Through many years of experimenting and researching, the Centers for Disease Control firmly states that there’s no link between vaccines and autism. The CDC also stated that vaccine ingredients do not cause autism. Between 1999 and 2001, thimerosal was removed or reduced to trace amounts in all childhood vaccines except some flu vaccines (quote). Thimerosal is a compound that contains mercury and mercury is a metal that is found on earth but is detrimental to human health.

While thinking about mercury and thimerosal it is important to consider the distinction between two separate mercury- compounds: ethylmercury and methylmercury. They are all entirely different materials. Methylmercury is formed in the atmosphere. When present in the body, this substance is typically the product of consuming certain forms of fish or other food. High amounts of methylmercury can damage the nervous system due to long-term exposures. In comparison to ethylmercury, which is formed when the body breaks down thimerosal. Due to low levels of exposure to ethylmercury and it is clear out of your blood and system faster in a short period of time; it proves that thimerosal should not be the cause of bodily harm in early childhood and eliminates the cause of lifelong problems. As a result, long-term exposure to methylmercury is more likely to cause mercury poisoning than short-term exposure to ethylmercury.

The Food and Drug Administration (FDA) was mandated by legislation in 1999 to determine the level of mercury in all the products that the agency supervises, not just vaccines. Today, the childhood vaccines that used to contain thimerosal as a preservative are manufactured into a single-dose vial, cutting the need for preservatives in comparison to multi-dose vials back then. Although thimerosal was removed in 1999 across the United States and other nations, the number of children diagnosed with autism has not decreased. Even though thimerosal and other preservatives were used in some vaccines, it was never used in vaccines such as the measles, mumps, and rubella vaccine (MMR) that people claimed to cause autism in children. However, the choice of whether or not to be vaccinated depends on the individual. They can opt out of vaccination if they feel like vaccines can cause long-term health issues. There is no law that mandates everybody to be vaccinated to form herd immunity. Therefore, vaccination can be a blessing or a curse in different people’s perspectives and medical understandings.

In modern times with the rapid speed of vaccine production in recent decades, the historical roots of immunization are frequently overlooked, causing people to underestimate the severity of the harm that vaccine prevents. In today’s society, we use many vaccines that help prevent many different diseases. Vaccination aids in boosting the immunity of an individual and helps to eliminate the pathogens and antigens in your body before it turns into a disease, causing infection. Aside from some downsides, the practice of vaccines has several benefits for both individuals and society at large. It is the responsibility of each person to ensure that others’ wellbeing is upheld and this starts with the vaccination against dangerous diseases. The misconception that vaccines are a source of autism is debatable for each person, but everyone has the free will to get vaccinated. To achieve a world that is free of infectious diseases, it can possibly be obtained through the embrace of vaccination practice.

References

1. Anderson, V. L. (2015, January). Promoting Childhood Immunizations. Retrieved from https://www.npjournal.org/article/S1555-4155(14)00743-0/pdf
2. Baker, J. P. (2008, February). Mercury, vaccines, and autism: one controversy, three histories. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2376879/
3. Beard, C. (2003). The Role of Vaccines and Vaccination. Avian Diseases, 47, 293-305. From www.jstor.org/stable/3298701
4. Djurisic, S., Jakobsen, J. C., Petersen, S. B., Kenfelt, M., Klingenberg, S. L., & Gluud, C. (2018, July 2). Aluminum adjuvants used in vaccines. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6373706/
5. Grassley, N., Kang, G., & Kampmann, B. (2015). Introduction: Biological challenges to effective vaccines in the developing world. Philosophical Transactions: Biological Sciences, 370(1671), 1-7. From www.jstor.org/stable/24504340
6. Lambert, P., & Siegrist, C. (1997). Science, Medicine, and the Future: Vaccines and Vaccination. BMJ: British Medical Journal, 315(7122), 1595-1598. Retrieved March 23, 2020, from www.jstor.org/stable/25176519
7. OFFIT, P., & MOSER, C. (2011). INGREDIENTS. In Vaccines and Your Child: Separating Fact from Fiction (pp. 71-88). NEW YORK: Columbia University Press. doi:10.7312/offi15306.5
8. Orenstein, W. A., & Ahmed, R. (2017, April 18). Simply put: Vaccination saves lives. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5402432/
9. Plotkin, S., Robinson, J. M., Cunningham, G., Iqbal, R., & Larsen, S. (2017, July 24). The complexity and cost of vaccine manufacturing – An overview. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5518734/
10. Rappuoli, R. (2014). INTRODUCTION: Vaccines: Science, health, longevity, and wealth. Proceedings of the National Academy of Sciences of the United States of America, 111(34), 12282-12282. From www.jstor.org/stable/43043122
11. Sutherland, A. (2013, April). The Thimerosal Controversy. Retrieved from https://vtechworks.lib.vt.edu/bitstream/handle/10919/80308/media_aimee-2.pdf?sequence=1&isAllowed=y   

Introduction

In this article, the beneficial effects of yoga will be discussed about some specific symptoms related to Complex-Post Traumatic Stress Disorder (C-PTSD).

C-PTSD is a condition most often caused by repeated and ongoing, severe interpersonal trauma, it is commonly seen in those who were subjected to chronic childhood abuse. The symptoms of PTSD as stated in the NICE guidelines include re-experiencing symptoms (e.g. flashbacks, nightmares, intrusive images, physical pain), avoidance of reminders of the traumatic event, hyperarousal (e.g. constant on edge, hypervigilance of threat, insomnia) and emotional numbing. In addition C-PTSD sufferers can also experience, difficulty controlling emotions, inability to trust, feelings of permanent hopelessness/worthlessness/differentness, regular suicidal feelings, dissociative symptoms (e.g. feeling disconnected to the world around them, the body, and ‘missing’ periods.) and risky or self-destructive behavior. The main focus here will be reconnecting with the physical body, emotional recognition, and regulation, and looking at methods of grounding and staying connected to the present moment, by using yoga as a complementary practice alongside regular treatment options.

Relationship between yoga and C-PTSD

As a mind and body practice, yoga has many benefits in beginning to connect to the physical body and experience embodiment in a safe environment. By using techniques such as meditation and pranayama (breath control) the participant can be allowed time to sit, focusing on something other than the trauma. They are noticing the sensations within the body about particular emotions, experiencing these as natural sensations, rather than something to be feared or avoided, and using the compassionate stance of yoga to accept these emotions without negative judgments.

Certain yoga positions such as a wide kneed child pose and breathing techniques such as full yogic breath or nadi shodhana (alternate nostril breathing) can stimulate the parasympathetic nervous system. There are several benefits to activating the parasympathetic nervous system during the process of recognizing distressing sensations. The vagus nerve releases a hormone called acetylcholine which helps the body relax and reduces the stress hormones cortisol and adrenalin which are often overstimulated in sufferers.

‘At the time of the traumatic event, the body is flooded with adrenaline and stress hormones, which have been proven to interfere with effective memory processing and consolidation. So instead of the traumatic memory being filed away in linear time, it becomes timeless.’ – Ryan, J. (yogabhoga.co.uk)

The vagus nerve can also help the sufferer process the trauma by stimulating the amygdala, the part of the brain that stores memory, this can allow the processing of trauma imprints to memory, allowing them to become rooted in time.

‘Work at the Trauma Center Yoga Program is based on the clinical premise that the experience of trauma affects the entire human organism—body, mind, and spirit—and that the whole organism must be engaged in the healing process.’ – Emerson, D. et.al (2009) p124

Many PTSD sufferers disconnect from the body because trauma is stored at a cellular level and is not fixed in time. If the sufferer comes into contact with a trigger they re-live the traumatic event as a full-body experience, time shifts, physical sensations are experienced, and sensory distortions occur. These symptoms are caused by an imprint on the cells similar in nature to the yogic concept of samskara. A samskara is a mental imprint, in full detail, left by all actions, thoughts, and intentions, that is the root of many habitual behavioral patterns. It happens on a subconscious level, without active consideration.

In PTSD the trauma leaves a full imprint of the trauma which is not housed neatly in memory, it reacts to triggers on a subconscious level. By using yoga to look inwards the sufferer can begin to regain control of the experience. By beginning to see the trauma as separate from the true self, the process of embodiment and grounding to the present moment can begin to take place. By realizing that they are not the trauma but a witness to it, a choice appears, either go with it and relive the trauma – effectively re-traumatizing or begin to recognize the bodily sensations and/or thought processes that lead up to the flashback or other reliving symptoms and nip it in the bud. By using mindful meditation, grounding techniques, breath work, and movement. This gives the sufferer space to begin to work in a therapeutic setting.

Taking a trauma-sensitive approach to teaching yoga is very important to prevent the sufferer from becoming overwhelmed by the experience. Emerson, D. et.al suggest 5 aspects of the traditional yoga class that need to be addressed; Environment, Exercise, Teacher qualities, Assists, and Language. These are all important elements within any regular yoga class but are particularly important with trauma survivors.

The environment needs to be welcoming and safe, avoiding anything that may be a possible trigger to allow the participants to feel less vulnerable. Time should be taken with a gentle opening to let the participants settle into the space and begin to create a non-judgmental environment to begin exploring with movement and breathwork.

The asana would depend upon the group’s capabilities and stage of treatment, giving lots of options to explore how it feels in the body, or to opt out if overwhelmed. Focusing on allowing the participant the choice to do what they want with their body, empowering them to take charge of what happens to them.

“No, I will not be in pain. My opinion about what is happening to me matters, and I can take control.” – Emerson, D. et al (2009)

Extra care needs to be taken with hip openers because positions e.g. happy baby may be prompting. They will need to be gradually introduced step by step to allow the student to experience these positions in a state of safety

Savasana may also be problematic so approaching it more loosely and giving seated options as well as different lying positions.

The teacher needs to be welcoming, open, approachable, and able to adapt on the spot if something unexpected happens. Allowing the students to explore and experience in their own way and at their own pace whilst maintaining a safe environment.

Assisting needs to be focused and efficient, physical adjustments may not be appropriate for many months if at all. Verbal cues can work much more effectively to give guidance whilst allowing for safe personal space. If approaching the participant this should be done clearly so they know where the teacher is at all times.

Language should be clear, avoiding possible trigger words. Encouragement and invitation in the instruction avoid the possibility of participants feeling coerced and let them choose what to do or not do depending upon what they are experiencing.

In conclusion, the inclusion of a trauma-sensitive yoga practice would be beneficial to complement the traditional talking therapies used to treat C-PTSD. Taking this approach would allow for a full body treatment and give the participants the tools needed to safely undertake the complex psychological work within the therapeutic setting. 

Over the past century, there have been many developments in Optometry that have transformed the way in which practitioners conduct examinations and diagnose patients. Although such transformations have been introduced with the objective of enhancing the practitioner’s ability to identify and rectify vision-related conditions and to provide the patient with the best possible eye care, developments such as Behavioural Optometry, also known as Vision Therapy, have become debatable amongst Optometrists and scientists with regards to its validity and effectiveness in practice. Vision therapy is described as a process whereby a practitioner employs a specific therapeutic regimen in order to address vision-related disorders. This can be applied to both older and younger patients with the aim of reducing the development of vision disorders, providing them with a form of rehabilitation for disorders that have developed or optimized their visual skills in order to achieve effective visual performance. Through an analysis of both Doyle and Barrett’s articles, the differing views on behavioral optometry can be observed and a critical judgment can be applied.

In his article, Vision Therapy in the modern Behavioural Optometry Practice, Doyle aims to display the advantageous perspective of Behavioural Optometry and how it can be used as effectively as a traditional evidence-based practice to diagnose a patient. Through referring to various research papers, Doyle explains Behavioural Optometry as the “oculomotor integration with the head, neck, limbs and overall body to form temporality efficient and coordinated vision”. He represents the validity of Behavioural Optometry by mentioning its history in the 1930s and how it has been further developed over time through further research. This can be seen where the Optometric community came to the realization that there could be further forms of treatment for vision-related disorders other than the use of traditional lenses. The practices of French Ophthalmologist Louis Javal justify this as he formulated and utilised non-surgical means for the correction of strabismus, a condition which is usually corrected through the use of lenses. Such practices which are shown to be successful from an era of low technological advancements represent the foundational evidence that behavioral optometry can be used in diagnosing vision disorders.

Throughout his article, Doyle aims to represent his support for Behavioural Optometry and seeks to represent it as an effective and valid remedy for vision-related disorders. This can be seen through a 2011 study “Treatment of symptomatic convergence insufficiency with home-based computer orthoptic exercise program” which showed patients with symptomatic convergence insufficiency. It presented that a twelve-week course of home-based computer therapy programs showed significantly greater improvement in both near points of convergence and positive fusional vergence in both adults and non-communicating children in comparison to typical lens correction remedies prescribed by optometrists. He further proves his point by disregarding Barrett’s statement of “further assessment of whether convergence insufficiency can be permanently resolved in an individual or whether repeated treatment is needed” by mentioning the CITT Investigator Group’s research in their article “Convergence Insufficiency Treatment Trial” where they conducted these practices on patients on regular intervals for a year and found that most of the symptoms were eradicated but the consistent treatment of 12-24 visits in a year was required. However, this consistency applies and is always required for a successful outcome with any form of a vision disorder remedy.

Doyle further emphasizes the effectiveness and validity of Behavioural Optometry by mentioning the article “The efficiency of vision therapy for convergence excess” which illustrates the effectiveness of such practices on older patients who suffered from esophoria. Through their clinical trial, they were able to eliminate symptoms of esophoria in 80% of the patients after five months of sequential therapy procedures which goes to contradict Barrett’s statement of “the role of orthoptic exercises in the treatment of esophoria, however, remains unclear and needs further study” as through this study and the result it produced, it is clearly evident that Behavioural Optometry is both effective and valid in its ability to act as a remedy for those suffering from vision-related disorders.

The effectiveness of Vision Therapy can be further emphasized when Doyle mentions its ability in aiding “vulnerable groups” such as children with intellectually limited capabilities. Although Barrett agrees that most referrals from doctors to Behavioural Optometrists are mentally ill children, he does not see “evidence that optometrists adopting a behavioral approach can offer therapy that will positively influence the lives of these children”. In such cases behavioral optometrists only attain the role of diagnosing factors from these diseases which affect the visual system. It is very common for children from these population groups to not be able to read, write or have a basic education level due to their inability to see or concentrate properly. Doyle mentions the article “Optometric Vision Therapy for Visual Deficits and Dysfunctions: A suggested model for evidence-based practice”, where it was found performing simple exercises such as matching numbers together allowed substantial eye movement with concentration to occur. Through consistent practice time, which is tailored to each patient, there was a significant gain in the patient’s comprehension levels, oculomotor readiness and visual attention. Henceforth, Doyle has effectively shown how Visual Therapy is both an effective and valid means of therapy for a wide range of populations including older adults and “vulnerable” mentally impaired children.

In his article “A critical evaluation of the evidence supporting the practice of behavioral vision therapy”, Barrett seeks to justify his view on the ineffectiveness and baseless evidence surrounding Behavioural Optometry. Through targeting ten separate groups which Behavioural Optometrists are currently treating, Barrett concludes that “there is a lack of controlled clinical trials to support behavioral management strategies”. However, throughout his article Barrett makes conflicting and baseless claims which see him diverge away from his conclusion. This can be seen through his justification that Behavioural Optometry practices are ineffective in treating conditions such as Dyspraxia in children. Although Barrett agrees that symptoms such as reading and learning difficulties are directly related to dysfunction in the visual system, he seeks to disagree with the idea that vision therapy can lead to an improvement in these symptoms. He represents his justification as rather unsatisfactory as he mentions a report published in an Ophthalmic Literature Journal drawing effective correlations between behavioral optometry practices and improvements in the vision of those suffering from Dyspraxia. Although the evidence seems to exist about the effectiveness of behavioral Optometry in this field, due to “little concrete evidence” existing, Barrett views these practices as baseless and ineffective.

Bennett’s conflicting views can be furthered through his view on the use of low-plus powered lenses at near to slow the progression of myopia. In the studies of Zadnik, the behavioral approach to reducing myopia in younger patients is adding small plus powered lenses, such as +0.25D, +0.50D and +0.75D, to aid them in their accommodation. These lenses will enable them to exert less accommodative power and clinically has been found to reduce the progression of myopia as proven effective by the studies of Rosenfield and Gilmartin, both of which Bennett refers to. However, Bennett makes note of a 2003 study where it is seen that only moderate powered plus lenses of +1.50D and above will contribute effectively in the reduction of myopia progression, and further mentions that little reference was made of weaker powered lenses which are used by behavioral optometrists. He further proceeds to state that even though “behavioral optometry can explain this result, this does not necessarily mean that that the behavioral view is correct”, representing his conflicting claims when he has clearly stated the effectiveness of the behavioral approach. At the same time, he takes stance with the non-behavioral approach for sole reason that the “non-behavioral approach also explains the result”. This represents Bennett’s biased towards behavioural optometry, aiming to prove its ineffectiveness and invalidity on unsatisfactory grounds.

Further down his article, Bennett attempts to make mention of the ineffectiveness of behavioural optometry practices in sports vision. Mentioning the controlled studies of both Wood and Abernethy in 2001, who conducted behavioral optometry practices on various athletes and found “significant pre-to-post training differences were seen in the results of some measures”, signifying the effectiveness, to a certain extent, of behavioral optometry on athletes and their motor and vision abilities. Bennett however, interprets these improvements in the results as the athletes attaining “test familiarity”, stating this with no scientific research to back it up, displaying how he is attempting to force his conclusion. The views of Bennett can further be contradicted by the 2012 study “The Impact of a Sports Vision Training Program in Youth Field Hockey Players” where after conducting vision therapy on a group of hockey players, improvement was seen in their peripheral perception and their ability to track moving items. Through these various studies, it can be seen that the effectiveness of vision therapy in sports can date back to early 2001 and is continually showing its effectiveness in the modern era.

Through analyzing both the articles of Doyle and Bennett, the two different views on behavioural optometry can be explained. Although Bennett attempts to prove the ineffectiveness of vision therapy in modern-day practice, he does so in an unsatisfactory manner where he constructs baseless, conflicting, and biased claims in order to forcefully achieve his conclusion that “there is a lack of controlled clinical trials to support behavioural management strategies”. Doyle on the other hand presents vision therapy as both an effective and valid means of treatment that can and is being used for a variety of population groups. Through his presentation on the history and current use of behavioural optometry practices, which are backed by valid scientific research, he effectively invalidates Bennett’s conclusion and ultimately presents behavioural optometry as an effective form of vision management that can be as effective as the traditional evidence-based practice across all patient types.

Often, we encounter social issues that may indirectly influence our personalities. There is a need for therapy that can help us reform or face the realities of life. Wilderness therapy is such a therapy: this mode of psychological treatment relates to clinical medicine. It dates back to the 1940s when it was proven effective in enforcing experimental education and self-improvement programs. Precisely, it can be defined as a form of behavioral healthcare program in which an individual is given different tasks in a unique environment to enable them to exploit various challenges. The ‘wilderness’ aspect comes in the fact that the individual is normally put in a different environment, usually a forest, and allowed to interact with their group members.

Unlike other forms of psychological therapy, this therapy brings out the best results. With the outdoor setting of the medication combined with the supervision of qualified personnel, those taking the therapy are provided the many opportunities to reflect on their lives. The therapy can be administered either in groups or individually. The more productive of the two types is group therapy because it allows one to interact with others and build teamwork. The therapy helps in learning how to overcome different challenges through experimental education and the association that one is put through.

Programs

Many programs have been proposed by the pioneers of the industry. However, given that, the therapy is behavioral, most companies have come up with different programs that aim at solving different problems individuals face. The choice of such programs depends on the age, gender, and the nature of treatment one is looking forward to getting. The therapy can either be child, teenage (adolescent) adult-based. In most cases, the programs are distinguished by age groups and range from 10-17 and 18-28 years. Each program selected targets the different psychological problems that one is facing.

Benefits

Wilderness therapy focuses on shaping one behavior and giving them a sense of belonging. Studies show that the therapy is effective in eradicating:

• Suicidality
• Anxiety
• Relationship Depression
• Dependency on drugs and substances
• Aggressiveness
• Impaired school performance
• Poor peer relationship
• Sleep disruption
• Defiance

Note that the benefit of wilderness therapy in shaping one’s behavior depends on the nature of the program one is put through. The therapy has proved effective in transforming individual-based behavioral and personality disorders. Those who have undergone the therapy fully report a change in how they relate to others in society. Notably, therapy seeks to transform one’s behavior and make one product in the community.

Who should go for the program?

These programs are open to all individuals facing various behavioral issues. It is mostly recommended for those addicted to drugs and substances and looking forward to reform. Adolescents and adults facing issues like suicidality, drug abuse, abusive relationship, and other social problems are ideal for the program. Since we all face personality and behavioral issues in society, wilderness therapy is ideal for anyone interested in correcting their personality disorder. For instance, the fear of heights can be easily removed by the various activities incorporated into the therapy programs.

How it works

Wilderness therapy aims at inflicting a sense of belonging to individuals through a series of outdoor tasks and challenges. Ideally, people who are confused about life; do not know why they are living today and why they should live to see another day. The therapy takes advantage of nature and exposes an individual to the free world allowing them to develop a relationship with people and the environment as a whole. It teaches one to let go of what they cannot change and make adjustments on those aspects of life that they can change. For instance, those involved in abusive relationships can be advised on how to bond with others through teamwork. The aftermath of wilderness therapy is an ultimate change in one’s behavior.

One learns easily how to relate with people through multiple activities and tasks they are put through such as river rafting, backpacking, and rock climbing. When one is put in a different environment, one naturally adapts to a different personality. Therefore, wilderness therapy works by engaging through experimental and outdoor education.

Choosing a program

When selecting a program that will suit you, it is advisable to consult professionals in the sector. The wilderness therapy programs are designed to solve different behavioral needs. Children or adolescents have a different therapy program from adults. Factors to consider when choosing a therapy program include age, fee, location of the program, program package, age, gender inclusion, and many other factors. Those intending to get an actively engaging experience should choose a program offered by an experienced company in the industry. This will guarantee them a thrilling experience as the companies apply different approaches to their programs.

Controversies

Wilderness therapy is surrounded by disputes based on its ability to cure personality and behavioral disorders. In order to ensure that companies offering wilderness therapy are consistent with their marketing claims, they have faced criticism from other advocates who are calling for extensive research and standardization in the industry. Compared to boot camps, wilderness therapy programs have reported accidental death and abuse. Some critics argue that wilderness programs provide a less appealing environment for experimental learning.

The states have no valid records to prosecute the companies offering wilderness programs in case of accidental deaths and abuse. Also, some individuals have been escorted to wilderness programs forcefully. Psychologists claim that this action reduces the effectiveness of a therapeutic program individuals are put.

Conclusion

Wilderness therapy is one of the most effective methods of psychological healing. For many decades, this method has been used by psychologists to place individuals in different therapeutic programs that can help them change their behaviors and personality. The concept applies the role of nature in influencing behavior. Given the many challenges that individuals encounter in changing their lifestyle, for instance, the withdrawal effects of addiction, wilderness programs ensure no relapse. In most cases, individuals are put into groups while undergoing the program. This helps them heal from trauma, anxiety, and other disorders that directly influence their personality.

The aftermath of wilderness programs is beneficial to most individuals. Individuals who have attended the programs have reported a change in personality and behavior. In some cases, individuals may be enrolled in wilderness therapy programs. To avoid any relapse, parents consider taking their children to a therapeutic boarding school. Notably, the effectiveness of a wilderness program depends on the choice of the program based on the problem one is undergoing.

Case study for non-medical prescribing

This case study aims to demonstrate the safety assessment of a patient, formulating a diagnosis, deciding on treatment, and planning his care. Moreover at the heart of it is to demonstrate the ability for safe prescribing and evaluation of patients as an NMP. Throughout this piece, the ten RPS competencies are taken into consideration and a selected Consultation model is used to provide an assessment structure, this had to be straightforward, practical, and provide guidance to meet the patients and my needs. It is this that enables advanced nurses to a new medicalized role (Beaumont, 2012).

Non-medical prescribing was initially discussed in 1986 as a way of making improvements to delivering care, from a limited list of items agreed upon by the DHSS. The DOH went on to publish a report outlining recommendations for nurse prescribing (Crown Report, DOH,1989). Its’ intention was that this would lead to improved patient care, improved use of both nurses’ and patients’ time, and improved communication between team members because of the clarification of professional responsibilities. (DOH 1989). Training for non-medical prescribing did not start until 2002 and has now been expanded to include other professionals.

In my practice as an Uro- Oncology Clinical Nurse Specialist in the Secondary Health care setting the need for a more autonomous ability to practice and gain the qualification to prescribe independently is encouraged and supported. It is hoped this works toward building a flexible and dynamic workforce (Van Ruth et al,2008). I have worked in the field of Urology for my entire career and welcome a further qualification to enhance my practice. One study highlighted nurses felt that there were concerns about the effects on the role of the nurse blurring the boundaries between nursing and medicine Latter et al (2005) Another study demonstrates the benefits to be able to deliver complete care episodes, improve a multi-professional working, ease of access to medicines and improved patient information about medicines (Avery et al.,2004)

To become an independent prescriber, The Royal Pharmaceutical Society produced a framework in 2016 outlining the knowledge, skills, characteristics, qualities, and behaviors required for safe and effective practice by all prescribers. The tool has been promoted as effective for most but daunting to others. kat hall, Cathy Picton 2020. It lays out the need for improvement. There are ten competencies divided into two groups and I will be exploring these throughout this study.

My role involves running nurse-led clinics and assessing patients independently, formulating a treatment plan, and reviewing appropriately. The first RPS competency is assessing the patient. The patient chosen for this study is a 65yr old man who presented to the Urology department with an elevated PSA and he had undergone a prostate biopsy to rule out cancer. The histology concluded he was suffering from Benign prostatic hypertrophy and he attended my clinic for his results. He will be referred to as Mr. X to maintain confidentiality and protect his identity ( HCPC 2017). To establish a rapport and gather the information, I discussed the initial presenting complaint of elevated PSA and explained the histology findings from his biopsies, he was naturally relieved not to have Cancer. He complained of lower urinary tract symptoms (LUTs) including poor flow, nocturia x 3, incomplete emptying, and daytime frequency. LUTs symptoms occur in up to 30% of men ages over 65yrs (Abrams P 1994). He completed an International prostate symptom score questionnaire to give a clear outline of his symptoms and aid with the management plan. In 2012 LUTs in men were the subject of a NICE quality standard and his assessment included all the recommended investigations (NICE quality standard 45) Mr. X had completed a standard questionnaire which is a patient-reported outcome measure, the International Prostate Symtom Score( IPSS), assessment of his symptoms from his perspective (Barry et al,1992) It is a valid and reliable tool and is widely used (Lujan Galan et al .,1997) Digital rectal examination (DRE) had previously been done and a frequency volume chart, which is extremely useful in the assessment of men with bothersome LUTs (NICE guideline 97).

To carry out a full assessment and get an accurate medical, social, and medication history including drug allergies I chose to use the Calgary-Cambridge model (Kurtz et. al,2003). Prescribers are encouraged to do a consultation in a structured way (national prescribing center, 2003). The model has five steps covering both disease and illness frameworks. It is both comprehensive and evidence-based. The disadvantage of this model is that there are seventy-one micro skills not all of which are required for each assessment. It helps to build the relationship with the patient using the appropriate skills for the individual. Mr. X was greeted and my role was explained. Open questions were used to establish a rapport and gain his understanding of his bothersome symptoms, listening without interruption. The information was gathered and summarization was used to ensure he understood and that I understood his perspective. His LUTs had been ongoing for twelve months and had got worse since his biopsy. He had no past medical history other than an appendicectomy as a child and was not on any medication. He was fit and well with a keen interest in walking, doing 2 miles every day to maintain his health. There were no known drug allergies. He was married with a daughter, retired as an engineer, and had no family history of ill health.

I chose not to use other models such as McWhinney’s Disease-Illness model (1986) as whilst being a simple model it focuses on the clinicians’ agenda and is often referred to as the ‘disease Framework’.I felt a more integrative holistic approach was needed knowing he had concerns about cancer and I wanted to address some lifestyle intervention for his symptoms. Lifestyle interventions are extremely influential with LUTs, nicotine, and Caffeine universally reported as the two most significant bladder irritants (Arya et al 2000). All men undergoing assessment are advised to eliminate both to improve symptoms. Other beneficial lifestyle modifications are weight loss, pelvic floor exercises, fluid manipulation, and avoidance of certain foods and drinks (Lohsiriwat et al 2011) Mr. X was consuming large quantities of Caffeine during the day and we discussed how changing to de caffeinated Tea and Coffee would contribute to improving his symptoms.

The medical management available to him was explained, and by this point, we had established a good rapport and he was keen to explore all the available options open to him. The Calgary ‘Cambridge model (2000) is useful in achieving concordance as its focus is on building a relationship with the patient and maintaining a patient-focused discussion. Pharmacological management, of Benign prostatic hypertrophy causing obstructive symptoms, comprises two classes of medication-alpha blockers (e.g. Tamsulosin, Alfuzosin) and 5-alpha reductase inhibitors(5-ARI) (e.g. Dutasteride, finasteride). The pharmacokinetics of the two drug classes differ vastly: alpha-blockers have a rapid onset of action (24-48hrs), while the 5-ARIs take 3-6 months to reach peak effectiveness (Nazlund et al 2007). The NICE quality statement 6 states that men with LUTs receiving alpha-blockers should have their medication reviewed after 4-6 weeks (Nice website 2014). This consultation has been written from the perspective of a prescriber, the Consultation was done in the presence of a qualified prescriber who issued the prescription as per requirements by HCPC prescribing standards (reviewed 2021).

Moving the Consultation to the explaining and planning phase and working towards a shared decision we reviewed together all of the results and assessment documents it was clear that Mr. X had poor flow, a significant residual volume of 200mls, and severe bothersome symptoms with an IPSS score of 20 (Barry et al.,1995). Following discussion and looking at the information, he was provided we decided, as per NICE guidelines, to commence him on Tamsulosin 200mgs daily. This drug cannot be prescribed in people with severe hepatic impairment, a history of postural hypotension, history of micturition syncope. Caution has to be taken in prescribing it to people with severe renal impairment (eg GFR less than 30mlminute1.73m2). After cataract surgery, there is a risk of intra-operative floppy iris syndrome. In elderly people, vasodilatory effects may cause a rapid reduction in blood pressure and lead to fainting. Mr. X was advised to take the first dose at bedtime and to lie down if he experienced dizziness, fatigue, or sweating until they abate completely. He was also warned of the risk of retrograde ejaculation and erectile dysfunction.

In prescribing this drug the NMP holding the prescription qualification must prescribe in line with the requirements of the NMC code and their scope of practice. Prescribing must be in line with the relevant legislation, policies, and standards that underpin the code 9nmc section 18.1) The NMC adopted the ‘Royal Pharmaceutical Society Competency for all prescribers as standards of Competency for prescribing practice. It lays out all the steps for safe practice, all prescribers must take individual responsibility for their prescribing decisions.

Prescribing safely, appropriately, and cost-effectively is part of the treatment planning, taking into consideration the influences on prescribing practice along with the roles of and relationships of others involved in supplying and administering medication. The RPS’s Competency framework ensures a standard and benchmark of quality for prescribing and ensures that prescribing safety is maintained. It encompasses Professional accountability, advice about medicines, and ongoing management of patients using medication (RPS 2016).

Drugs have to be licensed through the Medicines and Healthcare Products Regulatory Agency (MHRA) or European Medicines Evaluation Agency (EMEA) to be used in the UK. In the NHS new drugs have to have approval by National Institute for Health and Care Excellence (NICE). These organizations look at the evidence of how effective a drug is, its limitations and drawbacks, and cost-effectiveness. When prescribing the hospital will have gone through the process and decided which drugs are the most clinically effective, safe, and cost-effective for patients. Tamsulosin is a selective alpha 1A and alpha 1B adrenoreceptor antagonist. Antagonism of these receptors leads to the relaxation of smooth muscle in the prostate and detrusor muscle in the bladder allowing for better urinary flow. It is a cost-effective treatment with a 73% reduction in the need for surgery. (online ref) Other alpha 1 adrenoreceptor antagonists developed in the 1980s were less selective and more likely to act on the smooth muscle of blood vessels, resulting in hypotension (Chappel et al 1996). Tamsulosin is on the hospital formulary and the first-line drug of choice as per local guidelines.

Nonmedical prescribing in the team context is required for it to work effectively. There is an ever-increasing demand for the Urology service requiring innovative development of roles leading to a more accessible service(Kean et al 1971) This has been acknowledged that across the NHS there is a need for streamlined, accessible, and flexible services (Department of health (DoH) 2000) and demands for practitioners to use their skills and knowledge to extend their roles beyond traditional boundaries and achieve their full potential (DoH 2001:2002). Each Trust has a non-medical prescribing lead who provides professional leadership and a coordinated approach to the maintenance and development of the NMP role (South Tees Hospitals NHS Trust 2008).GPs have restrictions on their formularies and only prescribe what is agreed upon by their Clinical Commission group. In issuing a prescription for Mr. X it must be a recognized and approved drug that his GP would be able to continue providing prescriptions for. The wider team involved in his prescription must be considered and involved. I reassured Mr. X that a letter summarising his Consultation including the plan would be sent to his GP to enable him to issue repeat prescriptions. Effective communication across the multidisciplinary team is of paramount importance to give clear and concise information on the assessment, treatment, and plan to prevent errors (Nadeem et al 2001).

The RPS competencies require the NMP to prescribe safely, professionally, and as part of a team. With the ever-rising demands on the NHS, non-medical prescribing remains under scrutiny.it is a requisite as an NMP to maintain a date with regulations and guidelines determined by the professional bodies. This incorporates education, and the legal frameworks for prescribing, supplying, and administration of medicines. The prescribing training courses have evolved and changed as it was thought they were not adequate in addressing diagnostic skills (Avery and Pringle 2005). Litigation costs have soared through the 1990s (Tingle 2002) highlighting my need for awareness of the legal process and the need for safe and effective practice. In considering the ability to work effectively in the legislative framework relative to practice the NMP can be seen to be linked with employer contact law being sure to work within the NMC and RPS standards of practice, professional accountability adhering to the NMC code of practice, Public accountability with the potential of Criminal law and patient accountability relating to potential Civil law. The Care Quality commission ensures the expected standards of care are maintained (Health and Social Care Act (2008) (regulated Activities) regulation 2014) Standard of conduct is set by my professional body, the NMC, Codes of conduct act as a principal set of rules and standards and provide a regulatory framework for prescribers.

The Consultation with Mr. X was drawn to a close with a plan to have him reviewed in the Prostate assessment clinic in three months. He was provided written information about his condition and treatment and contact numbers should he have any problems once starting the medication. Sometimes it is difficult to close a session down with patients feel nurses have more time than doctors (Silvermann et al 1998). Mr. X was satisfied with the outcome and left with a review plan and safety net in place.