Research Korner: Chronic Illness Examples

the effect of common skin disease on the QOL of patient in the local setting

My adviser wants me to modify the title from “quality of life of patient with skin disease in the local setting” to "the effect of common skin disease on the QOL of patient in the local setting” And my adviser also wants to modify the statement of the problem. Modifications are: STATEMENT OF THE PROBLEM 1.     What are the common dermatologic problems that patients seek for treatment @ Lucena Skin Center 2.     What extent does the dermatologic problem affects their life a.     performance of activities of daily living b.     relationship with people c.     how he perceives him self     3. Is there a significant difference among the 3 factors identified and the level of impairment?   Can you make those modifications for me in 7 days? Can you also limit the number of pages to 25 including the statistical computation, because of my budget limitations? Thankyou my advicer wanted our thesis change from comparative to descriptive correlational study.                                             Abstract STATEMENT OF THE PROBLEM:           This study aims to focus on the following research questions: 1.     What is the demographic profile of the respondents when they are grouped according to: a.     Age. b.     Gender c.     Diagnosis 2.     Is there any difference in the quality of life of patients with skin disease when respondents are grouped according to their demographic profile? 3.     Is there a difference in the level of the quality of life between those with skin disease and those without skin diseases?   LOCALE OF THE STUDY:           This study will be conducted among 263 patients with skin disease and 47 subjects without skin disease (controls) in Lucena Skin Center Clinic. A private dermatology clinic in Lucena City with a board certified dermatologist.               RESPONDENTS: The sampling technique used was criterion sampling. Both the inclusion and exclusion criteria for patient selection were adopted form the source. Consecutive patient's, age 15 and above, whether old or new, consulting for any skin problem were included in the study. The patient's companions whose ages were also 15 and above served as control subjects (Those who do not have skin diseases). The paramedical staffs were also recruited as control subjects. As in the original, the criteria for the selection of controls were that they should not have seen their general practitioner over the previous "3 months", they should have had no apparent disability. Excluded in the study were those who were illiterate or were unable to communicate in Filipino unless a reliable interpreter was present.   SIGNIFICANT FINDINGS:           The study was conducted among 263 respondent's patient and 47 controls (no skin disease) in Lucena Skin Center Clinic, Lucena City.           The demographic data were analyzed using descriptive statistics (N=263) for the patient and (N=47) for the controls. Majority of the patients where females, 142 (54%) and 121 (46%) were males. The respondents were aged from 15 to 78 years. 237 (90%) were aged less than 65 years where as 26 (10%) fell into the geriatric age group (age > = 65). For the control subset, 38 (81%) were female and 9 (19%) were males.           A total of 263 subjects responded to the IKPAS (Translated Dermatology Life Quality Index in Filipino). The average time to complete it was 5 minutes. Unanswered item was observed for item 9 on sexual activity. The difference of the mean score between 15-64 y/o group (mean score= 7.5) and 65-78 y/o group (mean score= 8.07) were not statistically significant however, the difference of the mean score between male (mean score= 7.4) and female (mean score= 26.19) were statistically significant. Among the diseases, the findings with the highest mean score (greatest effect on the quality of life) were seen in Atopic Dermatitis (11.5) and the lowest mean score in Viral Warts (4.5). IKPAS was also completed by 47 healthy control subjects. Reliability was measured in the translated instrument using the 's alpha Coefficient and it showed internal consistency with  alpha Coefficient of a=0.71 (acceptable is >0.7). There was a significant difference between       mean scores of patients (7.86) and healthy subjects (0.89) (p=0.000), demonstrating construct validity. Quality of life scores were higher in inflammatory skin diseases such as Atopic dermatitis, Contact dermatitis, Erythroderma and Lichen Simplex Chronicus as compared to Acne, Viral warts and Keloids.           The first null hypothesis was: "There is no difference in the Quality of Life of patients with skin disease when respondents were group according to their demographic profiles".           The researchers reject the first null hypothesis.           The second hypothesis is: "There is no difference in the quality of life of patients with skin disease and those without skin disease"           The studies second null hypothesis was also rejected by the researchers.                             CHAPTER ONE THE PROBLEM AND ITS SETTING   BACKGROUND OF THE STUDY: During our duties in clinics and hospitals, we often encounter patients with skin diseases. We have observed that these patients were irritable, restless, and shy. They were treated for their skin problems only.           The nurses were instructed by the Physician/ Dermatologist how to take care of the patient's skin lesions and rashes but their emotional and psychological problem were not taken into consideration.           We were wondering whether the stress of having the skin disease affect their quality of life.           The concept of quality of life was developed to interpret data obtained about the impact of diseases on patients well being. This was fostered by the World Health Organizations (WHO) view of health as not merely the absence of disease or infirmity, but the ability of the person to lead a productive and enjoyable life. It usually utilizes a patient- administered questionnaire with items evaluating the effect of a disease and its treatment on patient's symptoms, feelings and daily activities. (called domain) over a well-defined period of time. [3] The response options are arbitrary and employ a scoring system for interpretation. [4]           This study was undertaken to examine the quality of life of patients with skin disease against those who do not have skin diseases.           By studying the impact of skin diseases on the quality of life of patients with skin diseases, the researcher hope to be able to modestly contribute to the enhancement of not only the nursing profession but also the medical profession and as well as the improvement of patient care quality to uplift their quality of life.   STATEMENT OF THE PROBLEM:           This study aims to focus on the following research questions: 1.     What is the demographic profile of the respondents when they are grouped according to? a. Age           b. Gender           c. Diagnosis 2.     Is there any difference in the quality of life of patients with skin disease when respondents are grouped according to their demographic profile? 3.     Is there a difference in the level of the quality of life between those with skin disease and those without skin diseases?     SIGNIFICANCE OF THE STUDY:           Research is the best way to find solutions to nursing problems and to set standards for nursing practice. The problem that we have observed during our stints in hospitals and clinics led as to conceptualize a study that will answer our curiosity. The results of this study will therefore, benefit the following sectors; NURSES- Expertise will increase as additional knowledge will be gain when educators will formulate effective psychological and emotional counseling which will be incorporated in nursing curriculum because of the output of this study. NURSING EDUCATION- Nursing schools will be able to incorporate the results of this study into their nursing psychiatry curriculum. PATIENTS or CLIENTS- there will be increased patients care quality. This in turn, will create increased patient satisfaction and will reflect a positive view of the hospital or clinic by the community. MEDICAL EDUCATION- Medical schools will be able to incorporate results of this study into their medical psychiatry curriculum. MEDICAL PROFESSION- Dermatologist will now be more aware and sensitive about their patient emotional and psychological problem brought about by their skin condition.     SCOPE AND DELIMITATION OF THE STUDY:           This study is conducted among 263 patients with skin disease and 47 subjects without skin disease (controls) in Lucena Skin Center Clinic. A private dermatology clinic in Lucena City with a board certified dermatologist.           A primary limitation of the study is posed by the source of the sample population which is from one local clinic only.   DEFINITION OF TERMS: ·        Quality of Life- it refers to the satisfaction derived by the respondents in terms of their performance in the activities of daily living namely; shopping/ marketing, the way they dress, socializing, participation in sports activities, going to work and school and performing sexual activity and cognitive functioning. ·        Cognitive functioning- In some forms of psychometrics, particularly those related to the  Type Indicator, the cognitive functions (sometimes known as mental functions) are defined as different ways of experiencing and thinking about the             world. They are defined as "thinking", "feeling", "sensing" and "intuition". ·        Demographic profile-  refers to the gender and age of the patient                                       CHAPTER TWO THEORETICAL BACKGROUND   REVIEW OF RELATED LITERATURE AND STUDIES   RELATED LITERATURE:           Quality of Life is the degree of enjoyment or satisfaction experienced in everyday life. [5] In biblical times lepers had to live outside of society. In medieval times they had to ring a bell and call "unclean" wherever they went. Catching leprosy requires living in close contact for a long time and many labeled as lepers probably had diseases like eczema or psoriasis that are not infectious. The stigmatization of lepers was not a public health measure to control the spread but a reflection on how people view those with skin disease. Simply having skin disease is bad enough but the social response of others makes it much more difficult. [6]           As early as 1985, Quality of life has been employed as a major endpoint to evaluate and compare therapies along with clinical outcome measures such as efficacy and survival. [7] In cancer therapy, for instance, the emphasis is on the side-effect and quality of life. [8]           In dermatology where most patients are seen in the ambulatory, care setting survival is not a major end point [9] and because the therapeutic modalities here have comparable efficacies, the use of quality of life became even more important. Several well-validated dermatology-specific questionnaires have been developed, the first being 's Dermatology Life Quality Index in 1983.   RELATED STUDIES: The effect of skin diseases on quality of life in patients from different social and ethnic groups in Cape Town, South Africa. (.; ) Skin diseases can greatly affect the quality of life (QoL). Little is known, however, of their impact on QoL in the developing world. This study was designed to assess the effect of skin diseases in such a setting. A questionnaire survey of patients using the Dermatology Life Quality Index (DLQI) modified to the cultural needs of the population. The adapted instrument was translated into Afrikaans and Xhosa. Six hundred and seven patients attending general dermatology clinics at  Hospital and 53 controls were recruited. Influences on QoL of clinical severity, employment, education, age, sex, and home language were examined. Participants included 313 (52%) English-speaking, 215 (35%) Afrikaans-speaking, and 79 (13%) Xhosa-speaking dermatology patients. Independent risk factors for having a high disability score were dermatologists' assessment of severity, younger age, unemployment, and language (odds ratio, 0.13; 95% confidence interval (CI) of 0.03–0.5 for Xhosa speakers compared to Afrikaans speakers). Gender was not associated with a high score, but females were more likely to report effects of skin disease on self-esteem, clothing choice, treatment problems, and     In this multicultural setting, social class and language group, but not gender, influenced the impact of skin disease on overall QoL. Xhosa speakers were apparently less affected than other patients. This could be due to cultural differences in the experience of skin disease and in the perception of disability, or to biases in questionnaire responses. Anxiety and depression were relevant dimensions of QoL in this study and should be considered for inclusion in future research. The adapted and translated DLQI was valid and reliable. [10] Eczema impairs quality of life in children to same extent as kidney disease. Children with serious skin conditions feel their quality of life is impaired to the same extent as those with chronic illnesses such as epilepsy, renal disease and diabetes, according to research published in the July issue of British Journal of Dermatology. A team of Scottish researchers surveyed 379 five to 16 year-olds, who had been suffering from skin diseases like acne, eczema and psoriasis for more than six months, together with their parents. They asked the children and their parents how much the condition impaired the child’s quality of life when it came to factors such as pain, loss of sleep, dietary restrictions, interference with school and play, friendships, teasing and bullying and medical treatment.   They then compared the quality of life scores given by the parents of 161 children with chronic diseases in the same age group. Only six of the 546 parents approached by staff at Ninewells Hospital in Dundee and Perth Royal Infirmary preferred not to take part in the research. All the children included were attending outpatient clinics at the two hospitals.    Key findings included: ·        The children in the study said that psoriasis (red scaly patches) and eczema were the two skin conditions that caused them the greatest distress. Both resulted in 31 per cent impairment in their quality of life score. This was followed by urticaria (itchy allergic skin rash) at 20 per cent impairment and acne at 18 per cent impairment. ·        From the parent’s perspective, eczema was the biggest skin problem at 33 per cent, followed by urticaria at 28 per cent, psoriasis at 27 per cent and hair loss at 19 per cent. ·        When they compared the overall results for the children with skin diseases and chronic illnesses, the researchers found that the condition that had the worst affect on quality of life was cerebral palsy at 38%. Generalized eczema and kidney disease both scored 33%t. ·        Cystic fibrosis also made the top five (32%t), followed by urticaria and asthma (28%), psoriasis (27%), epilepsy and bed wetting (24 %), diabetes, hair loss and localized eczema (19%) and acne (16%). ·        When children with psoriasis, and their parents, were asked to chose the things that affected the child’s quality of life most, parents rated bullying third and children rated bullying fourth. ·        Teasing or bullying was also a key concern for the 11 children with hair loss, with six of the children and nine of the parents putting it first on their list.   ·        The biggest concern for children with eczema, psoriasis and uticaria was itching or pain, while children with acne or warts said that embarrassment was their main worry. “Our study shows that children with chronic skin diseases – and their parents – reported the same level of quality of life impairment as the parents of children with many other chronic illnesses” says lead author Dr Paula Beattie from the Royal Hospital for Sick Children in Glasgow.           “Skin diseases are often more obvious to other children than chronic diseases such as asthma or diabetes and are more likely to lead to alienation, name calling, teasing and bullying. “Some skin conditions can also disturb children’s sleep and cause lack of self-confidence, embarrassment and poor self-esteem, especially as they get older. “Although skin diseases may not shorten life in the same way as serious conditions like cystic fibrosis, they can cause children as much, if not more, distress in their everyday lives.” According to co-author Dr , Consultant Dermatologist at Ninewells Hospital, Dundee and British Skin Foundation spokesperson: Measuring quality of life can be a powerful political tool as it provides the patient’s perspective on the health impact of different diseases. “This is particularly important when arguing for vital resources, especially in dermatology, as skin diseases are not considered to have as much of an impact on people’s lives as other illnesses. “Our study clearly shows the profound effect skin diseases can have on children’s quality of life and we hope that our findings will raise awareness of the problems they face and encourage greater sensitivity towards them.”  of the British Skin Foundation agrees: “All too often, people think of skin diseases like eczema as nothing more than a mere annoyance. Sadly, this simply is not the case. “We frequently hear of children who cry all night because of their itchy, flaky skin. This in turn leads to a lack of sleep and extreme emotional upset for their parents too. “The psychological impact of visible skin diseases can be massive, with children facing bullying because of the way their skin looks. We even hear of children not wanting to swim or take part in sports because they don’t want to have to reveal their skin in the changing rooms. Of course, this can lead to enormous stress for the patient’s family also. “This is why as a charity we are dedicated to raising money for research to end the diseases that blight millions of people’s lives in the UK.” [11]   THEORETICAL & CONCEPTUAL FRAMEWORK: We theorize that skin diseases affect patients' well-being and their ability to perform activities of daily living just like any other medical problem in the local setting. The concept of quality of life was developed to interpret data obtained about the impact of disease on the patient's well being. This was fostered by the World Health Organization (WHO) view of health as not merely the absence of disease or infirmity, but the ability of the person to lead a productive and enjoyable life. We conceptualize that quality of life can be measured by asking patients to answer a questionnaire which measures the effect of skin disease and its treatment on a patient symptoms, feelings and daily activities over a specified time.           The theoretical framework guiding this research is the concept that skin disease has an adverse impact on the quality of life of the patient.   HYPOTHESIS:           The null hypothesis that was used to guide this study was: 1.     There is no difference in the quality of life of patients with skin diseases when respondents are grouped according to their demographic profile. 2.     There is no difference in the level of the quality of life of patients with skin diseases and those without skin diseases               CHAPTER THREE METHODOLOGY RESEARCH DESIGN:           This non-experimental study uses the prospective quality of life survey and analysis.   LOCALE OF THE STUDY:             The setting of the study was at the Lucena Skin Center. A Dermatology Clinic manned by a Fellow of the Phil. Dermatological Society and a Fellow of the Phil. Leprosy Society. The clinic is situated in Lucena City.   RESPONDENT AND SAMPLING PROCEDURE:           Respondents were consecutive patients, age 15 and above, whether old or new, consulting for any skin diseases were included in the study. The patients companions whose ages were also 15 and above served as the control (those who do not have skin diseases) subjects. Both the inclusion and exclusion criteria for patient's selection were adopted from the source. As in the original, the criteria for the selection of the controls were that they should not have seen their general practitioner over the previous "3 months", they should have had no skin problem or other systemic medical disease over this time; and, that they should have no apparent disability. Excluded in the study were those with intellectual impairment or a psychiatric disorder, and those who were illiterate or were unable to communicate in Filipino unless a reliable interpreter was present.   RESEARCH INSTRUMENT:           We reviewed 3 different well validated dermatology-specific quality of life tools for possible translation. Both developed in the U.S, the Dermatology Specific Quality of Life (DS8QL) [12] had 52 items for acne and contact dermatitis cohorts while the revised SKINDEX [13] had 29 item tests for patients with any skin disease. The revised Skindex Categorized domain/scale into emotion, symptom, and functioning, and had 5 responses choices. Dermatology Life Quality Index [14] [15] [16] (DLQI), a tool developed in UK, was similar to Skindex in terms of generic coverage, domains, and responses choices but consisted only of 10 items which fit on a single sheet of paper, and was those chose for translation. Quality of Life research measures the effect of a disease and its treatment on a patient's symptoms, feelings and daily activities over a specified time. The Dermatology Life Quality Index (DLQI) questionnaire is a non-skin disease specific Quality of Life tool developed by Dr. Finlay. It consist of 10 questions and can be analyzed under the following headings: Symptoms and feelings (items 1 and 2), daily activities (items 3 and 4), leisure (items 5 and 6), work and school (item 7), personal relationships (item 8 and 9), and treatment (item 10). It is calculated by summing the score of each question (scored from 0 to 3) resulting in a maximum of 30 for the 10 items and a minimum of 0. The higher the score, the more quality of life is impaired.   TRANSLATION:           The original questionnaire was sent to 4 independent bilingual (English and Filipino) translators and their output were later "translated-back" by a bilingual lay panel consisting of 2 persons. The first item refers to the Symptoms (itchiness, pain, discomforts) while the second item on "hiya", which loosely translates in English as "embarrassments". Item 3 evaluates the effect on shopping or household chores while item 4 in the way of dressing. The fifth item is on social and leisure and the sixth item on sports and exercise. Items 7, 8, 9 and 10 concerns on work, school, relationships, Sexual difficulty, and treatment respectively. The following modifications were noted: (1) the tool was renamed IKPAS (Indeks ng Kalidad ng Pamumuhay ng may sakit sa balat), (2) the general patient data was omitted on the questionnaire except age, sex, and diagnosis to save on space, (3) a confidentiality clause was inserted on the introductory statement and includes the aim of the study. (4) 2 Filipino words ("Gaano" and "Paano") were used to encompass "How much" in the original, (5) and although the attempt was to do a literal translation without any loss of the concept, for item on household chores of house keeping, buying at the market ("Pamamalengke") was included; for item on leisure activities, watching movie ("Panunuod ng Sine") was given as an example; For the item on sports, the word "Ehersisyo" (Exercise) was incuded; "Sex" was used in the context of sexual difficulties in the original; and on the item relationship, "Asawa" (Spouse) was used for "Partner". Response choices scales were structured similar to the original and used the same scoring system: "Sobra-sobra" (score=3), "Sobra" (score=2), "Medyo/Oo" (score=1), "Wala/Hindi" (score=0), "Walang kinalaman" (score=0), and no answer (score=0). A higher score (total=30) indicated a lower unfavorable quality of life.   DATA COLLECTION:           The researchers collected the data from Lucena Skin Centers Clinic. Both the inclusion and exclusion criteria for patient selection were adopted from the source. Consecutive patients, age 15 and above, whether old or new, consulting for any skin disease were included in the study. The patients' companions whose ages were also 15 and above served as control subjects. The paramedical staffs were also recruited as control subjects. As in the original, the criteria for the selection of controls were that they should not have seen their general practitioner over the previous "3 months", they should have had no skin problem on other systemic medical disease over this time; and, that they should have no apparent disability. Excluded in the study were those with intellectual impairment or a psychiatric disorder, and those who were illiterate or were unable to communicate in Filipino unless a reliable interpreter was present.           The time needed to complete the questionnaire ranged from 1 to 36 minutes with the mean at 5.23 minutes. However, it is significant to note that 205 respondents (78%) took less than 5 minutes and another 39 (15%) took between 5 and 10 minutes to answer the questionnaire. This leaves only 19 (7%) who took more than 10 minutes to answer the questionnaire.   DATA PROCESSING AND ANALYSIS           Consecutive patients who passed the entire inclusion and exclusion criterion were politely asked to answer the IKPAS (translated questionnaire) after giving their permission.           When all the data were at hand, we computed the reliability of our translated questionnaire using the 's alpha Coefficient and then we analyze our findings on the effect of the skin disease on the quality of life of patients with skin disease and compare the findings with those without skin diseases. There was a significant difference between scores of the patients (6.89, SD: 4.55) and controls (0.89, SD: 1.8) (p=0.000), demonstrating construct validity.   RELIABILITY TEST TOOL:           When analyzing the reliability of your instrument, the best is to retest the subjects using the same instrument to see if the subjects are consistent with their answer. But researchers have devised a formula to compute the reliability of a survey instrument. The reliability test is called 's alpha coefficient. Its formula is:

the effect of common skin disease on the QOL of patient in the local setting

My adviser wants me to modify the title from “quality of life of patient with skin disease in the local setting” to "the eff...

LITERATURE REVIEW: CHILDHOOD IMMUNISATION

Literature Review   1. WHY IS CHILDHOOD IMMUNISATION IMPORTANT?   The human body has the ability to resist almost all types of organisms or toxins that tend to damage the tissues and organs. This capability is called immunity. Much of immunity is acquired immunity that does not develop until after the body is first attacked by a bacterial disease or a toxin, often requiring weeks or months to develop. An additional portion of immunity results from general processes, rather than from processes directed at specific disease organisms ( 2000).   For this topic, the article by  will be used for discussion. His article entitled ‘Addressing Parent’ Concerns: Do Vaccines Cause Allergic or Autoimmune Diseases?’ talks about anecdotal case reports and uncontrolled observational studies in the medical literature which claim that vaccines cause chronic diseases such as asthma, multiple sclerosis, chronic arthritis, and diabetes. This article was published on March 1, 2003 in the journal called .   According to the study, autoimmune diseases might occur after immunization because proteins on microbial pathogens are similar to human proteins ("molecular mimicry") and could induce immune responses that damage human cells. However, wild-type viruses and bacteria are much better adapted to growth in humans than vaccines and much more likely to stimulate potentially damaging self-reactive lymphocytes. Consistent with critical differences between natural infection and immunization, well-controlled epidemiologic studies do not support the hypothesis that vaccines cause autoimmunity.   Remaining without immunization for childhood diseases is a risk no child should face. Chronic illness of children has become a global concern. Although the etiology and types of chronic illness may differ from developing countries to developed countries, some aspects are universal.   With the advent of public health programs and a decrease in childhood mortality, large populations of children all across the globe are experiencing chronic disease states. Although accurate data from developing countries is sometimes questionable, there has been a steady decline in infant and child mortality and a concomitant increase in chronic disease in children across the world.1,2 Statistical predictions point to an accelerated transition from acute to chronic disease in the next 50 years (, 2004). Without immunization, children are in danger of getting chronic diseases.               Immunity can be active or passive. In active immunization, antibody production is stimulated by administration or antigen or by exposure to naturally occurring antigens such as bacteria, viruses or fungi. In passive immunization, preformed antibodies actively produced in another person or animal are given to the recipient in the form of serum γ-globulin. Childhood immunization comes in the form of active immunization.               Immunization programs against infectious disease need to be developed on a global basis and administered to all children on the planet. Communication and education are imperative and culturally sensitive, community-based programs that convey information on how to recognize, treat, and seek appropriate health care are required. This is particularly important for potentially devastating communicable diseases such as diarrhea and malaria. Frequently, persons from westernized societies expect cultures other than their own to embrace treatment approaches fostered by Western medicine. These approaches are often used by these cultures as a last resort after traditional healing practices have failed (, 2004).   Global chronic illness in children has multifactorial etiologies. Poverty, malnutrition, inadequate immunization programs for preventable infectious diseases, and environmental hazards play a significant role as causal factors of chronic illness in children ( 2004).   The organisms that cause a disease (or materials produced from those organisms) are weakened or killed and then made into vaccines. These vaccines are injected into the body or are taken by mouth. The body reacts by making disease-fighting substances - antibodies - that build up in the system and guard against these diseases for a long time, often for a lifetime. Thus, immunization helps the body to defend itself against a particular disease.   Because they have received antibodies from their mother's blood system, babies are immune to many diseases when they are born. But this immunity wears off during the first year of life (, 2004). That's why immunization programs, which help young bodies of the children build their own defenses against disease, should be started early and carried out faithfully. Immunizations are very important.   The eight childhood diseases (measles, mumps, rubella, diphtheria, tetanus, pertussis, Haemophilus influenzae type b, and polio) which are preventable by immunization, can, and do, cause crippling and, sometimes, death. These illnesses are serious and their complications can be terrible. With the exception of tetanus, these diseases are contagious. They can spread rapidly from child to child and from community to community. As long as children remain unprotected against them, serious outbreaks of disease - even epidemics - can occur.   All children should receive active immunization with diphtheria toxoid, the type of toxoid or combination used depending on the age of the child. Schick tests generally are unnecessary; instead of a follow-up Schick test, a booster dose of toxoid is given at the recommended time. For those over 12, the best procedure is to immunize or boost with tetanus-diphtheria toxoid, adult type.   Active immunization may be started at age 1 to 3 months, either with separate injections of pertussis vaccine or through the use of DTP (Diphtheria and Tetanus toxoids and acellular pertussis vaccine) vaccine. In either case, the manufacturer’s recommendations should be followed, since the dose may vary from preparation to preparation. For those over 6 years old, routine use of pertussis vaccine, either separately or in combination, is not recommended.   The initial DTP immunization series is followed by a DTP booster at age 18 months and another of 0.5 ml given when a child reaches school age. Subsequent routine tetanus boosters every 10 years should maintain protection. More frequent boosters are unwarranted since untoward reactions to toxoid may occur. At any interval after basic immunization, immunity can be reestablished by a single 0.5 ml s.c. booster dose; however, after an interval of more than 10 year since the last injection of toxoid, the rate of the booster response may be somewhat slower.   The fourth dose of DTP may be administered as early as age 12 months, provided 6 months have elapsed since the third dose and the child is unlikely to return at age 15-18 months. Tetanus and Diphtheria toxoid is recommended at age 11-12 years if at least 5 years have elapsed since the last dose of tetanus and diphtheria toxoid-containing vaccine. Subsequent routine Tetanus and Diphtheria toxoid boosters are recommended every 10 years ( 2004).   Usually, the parents of children who are with chronic and infectious diseases preventable by immunization support the immunization recommendations to help ensure that more people are immunized against the many chronic diseases like pertussis, or whooping cough, which is a highly contagious disease.   Pertussis immunity from early childhood vaccinations wears off, leaving adolescents and adults susceptible to the disease. Adults and adolescents may suffer from a severe and prolonged cough, vomiting and complications, as well as disrupted home and school routines. While some have relatively minor symptoms, anyone with pertussis can spread the infection to others, particularly infants who are too young to have been fully immunized. Infants are at higher risk for severe illness, complications and death, and 90 percent of unvaccinated children living with someone with pertussis will contract pertussis.   Primary immunization of infants with trivalent vaccine should begin at about age 2 months, integrating the schedule with other routine immunization procedures. For primary immunization of children up to 6 years old, three doses are given at approximately 8-week interval. Inactivated poliovirus is recommended for children with immunodeficiency diseases.   Measles immunization is recommended as a routine procedure for all susceptible infants or children. Live attenuated vaccine is the agent of choice in healthy children and is given at about 15 months of age, when about 95% of children have an antibody response. If exposure to measles is likely before that age, the vaccine should not be withheld; reimmunization at an older age may be necessary. Vaccine may be given to at any later age to those not vaccinated earlier.   Measles, mumps and rubella vaccine for second dose is recommended routinely at age 4-6 years but may be administered during any visit, provided at least 4 weeks have elapsed since the first dose and that both doses are administered beginning at or after age 12 months. Those who have not previously received the second dose should complete the schedule by the 11-12 year old visit ( , 2004).   While mumps infection is a largely benign disease when contracted during childhood, it becomes more dangerous in older children and adults, who are more susceptible to severe neurological, testicular, and ovarian complications from the infection. It is alarming to see that vaccination is clearly shifting the occurrence of this disease from young children toward those who are older ( 2003).   Three types of polio vaccines have been used throughout the world: 1) the OPV, or oral polio vaccine (Sabin vaccine), consisting of live, attenuated poliovirus; 2) the IPV, or inactivated polio vaccine (Salk vaccine), consisting of killed poliovirus and given by injection; and 3) the eIPV, an enhanced potency inactivated polio vaccine, consisting of killed poliovirus with high viral antigen content ( 2003).   Do vaccines protect us from the disease for which they are given? This question might seem absurd on the face of it, given the near disappearance of many infectious diseases for which vaccines are given credit.   Vaccines have been called potential allergens because they introduce foreign proteins directly into the blood without digestion or "censoring by the liver." When we remember that one of the chief causes of allergies is the presence of undigested proteins in the blood, the connection between vaccinations and allergies becomes apparent (, 1995).   Vaccines have also been called drugs because, like drugs, they are inherently toxic and work on the principle of suppression rather than expression, as do natural therapies. This suppression of symptoms prevents the body-mind from discharging what needs to come out and only compounds the problem. Also, the expression of symptoms is part of the full immunological response which is necessary for the development of true immunity (, 1995).   Perhaps the only real difference between vaccines and drugs is that drugs work to suppress present symptoms and vaccines work to suppress possible future symptoms. Orthodoxy regards this latter as immunity, but evidence suggests it is immune suppression (, 1995).               One theory used to explain the increased incidence of allergic diseases in children according to the article is the "hygiene hypothesis," which states that better hygiene is associated with an increased risk of developing allergies. Several epidemiologic findings support the hygiene hypothesis. For example, children are less likely to have allergies if they are part of a large family, attend child care, experience a large number of infections early in childhood, or come in contact with animals. On the other hand, children are more likely to have allergies if they live in areas of better sanitation, are not infected with helminths or worms, or live a "Western" lifestyle.               Over the years, vaccine-preventable diseases have been responsible for the illnesses and deaths of many infants, children and adults. Since the development and increased usage of vaccines, many diseases such as polio and measles have become very rare ( 2001).               An important way that parents and caregivers can help combat vaccine-preventable diseases is to keep copies of updated shot records of the child so that they can not miss an immunization. This could help the child a lot, even save his or her life, as there are instances that vaccine-preventable diseases can take lives.                                 2. IS FREQUENT BREAST EXAMINATION A MEANS TO DETECT EARLY ONSET OF BREAST CANCER?   Hope that regular self-examination of the breasts might protect women against dying from breast cancer was finally extinguished by a huge study that demonstrated it was useless, an article titled “Self-examination ‘useless’, breast cancer study finds” said.   The source of this article is the London paper . The author of the article is . This article was published on October 3, 2002. Although this was written in 2002, this topic is still relevant at present. The topic of breast cancer is one which has been around for years and will surely be around in the next few years.   The article summarized talks about mammography as a useful tool to try to detect breast cancer early in women over the age of 50 and to reduce a woman's chance of dying from breast cancer whereas for general public health policy it does not appear that breast self-exams are very helpful.   Cancer of the breast is the most common malignant condition among women and carries with it the highest fatality rate of all cancers affecting this sex. Breast cancer is rare in men, but when it does occur, it is usually not recognized, until late, and thus the results of treatment are poor.             Breast cancer appears to have reached epidemic levels. Talk to any group of people anywhere in the UK and they all seem to have some experience of it–someone in their family, a friend, a neighbor or work colleague. And it is not just a vague impression that this is the case, there are hard statistics to back it up. Every year around 39 000 women and between 200 and 300 men are diagnosed with breast cancer in the UK. Government figures show that the number of people who develop breast cancer every year has increased by 70 per cent since 1971, and by 15 per cent in the ten years to 2000. It is by far the most common form of cancer in women and the most common cause of cancer death in women (, 2004).   While history, physical examination, and mammography or thermography may strongly suggest breast cancer, the diagnosis can be made only by microscopic examination of tissue removed by open or aspiration biopsy.               Human breast cancer appears long after the organ finishes its development. Age is associated with the location of the tumors. The area of the breast where breast cancer originated was more central in the older patient population we studied. Breast tissue involutes first in the lobular parts and then in the larger central ductal structures.   Declining ovarian function in the premenopause leads to regression of epithelial structures and stroma. The central duct system remains but the lobules shrink and collapse. The last structures to appear with sexual maturity are the first ones to regress. This is reflected in the location of breast cancers in younger as opposed to older women. The cancers originate first in lobular ducts and later in the larger ductal structures (, 1999).   Breast cancer probably originates in an involuting target organ with a time relationship between the histogenesis, histoapoptosis, and development of breast cancer. It is surprising that breast cancer does not originate in the developing organ, as is the case for nearly all other epithelial and stromal cancers, which usually initiate and grow in regenerating or rapidly developing tissues. It is rare for breast cancer to develop before the age of 24. This is exactly the time when normal involution starts in most women. Involution of human breast tissue is well known to clinicians through mammography or magnetic resonance imaging and is a normal aging process. The development of breast cancer in involuting tissue argues that susceptibility to breast cancer is probably created much earlier in life (1999).             Many, if not most, ailments of the body cause pain and this includes breast cancer. Cancer pain syndromes can result from the progression of the disease or from efforts to cure or control the disease ( 2004). The sense organs for pain are the naked nerve endings found in almost every tissue of the body. Pain has been classified into two major types: fast pain and slow pain. Fast pain is felt within about 0.1 second after a pain stimulus is applied, whereas slow pain begins only after 1 second or more and then increases slowly over many seconds and sometimes even minutes ( 2000).   Fast pain is also described in many alternative names, such as sharp pain, pricking pain, electric pain and acute pain. Acute pain is generally the result of a specific injury and can be clearly explained in terms of where we feel it in the body. This type of pain is felt when a needle is stuck into the skin, when the skin is cut with a knife, or when the skin is acutely burned. It is also felt when the pain is subjected to electric shock. Fast, sharp pain is not felt in most deeper tissues of the body.             Slow pain also goes by multiple additional names, such as slow burning pain, aching pain, throbbing pain, nauseous pain, and chronic pain. This type of pain is usually associated with tissue destruction. It can lead to prolonged, unbearable suffering. It can occur both in skin and in almost any deep tissue or organ. Chronic pain is the other type of pain which is so called because it can continue for months or years and even trigger additional health problems such as depression and lead to lifestyle changes in attempts to remedy the situation.       Breast cancer presents a type of slow or chronic pain. This pain largely results from overstimulation of nerve endings. The nerve endings may be stimulated by inflammatory substances that are produced by damaged cells from the cancer and released from the surrounding capillary network.   The evidence that endogenous sex hormones influence risk of breast cancer has been reviewed extensively elsewhere; for pubertal girls, however, the modulation of endogenous estrogens is much more important. The main difference between high and low risk women for breast cancer is the persistent difference in serum estrogens secondary to early and late menarche. In addition, the serum levels might be further modulated to a great extent by nutrition, body fat, and exercise during puberty. Adipose tissue converts androgens to estrogen by aromatization. Bodies weight (fatness) influences additionally the direction to potent and less potent forms of estrogens (catecholestrogens). Late pubertal development and late menstrual patterns are thought to result in part to smaller amounts of body fat ( 1999).             Breast Cancer Campaign funds independent research into breast cancer at centers of excellence throughout the UK. The Charity aims to find a cure for breast cancer by funding research which looks at improving diagnosis of breast cancer, better understanding how it develops and ultimately either curing the disease or preventing it.             Friends and relatives can be a major source of support, but face their own difficulties. They have to provide emotional support, physical care and help in making decisions about treatment. Many of the observations about the impact of cancer are as true for them as for the patient. Their response to the illness depends on things such as their relationship to the patient, the stage of the disease and their own personalities.               It is important that healthcare professionals, especially the nurses, examine the breasts of male and female clients. A small amount of glandular tissue, a potential site for the growth of cancer cells, is located in the male breast. In contrast, the majority of the female breast is glandular tissue.               Early detection is the key cure to breast cancer. It is therefore a major responsibility for nurses to teach clients health behavior such as breast self examination. Studies suggest that only a minority of women perform breast self-exams ( 2004).               Surgery, radiotherapy, and chemotherapeutic agents are the major modalities used to treat patients with cancer, though various biologic therapies are beginning to have a significant impact. The basic problem is to make available drugs (natural products or synthetics) that kill cancer cells effectively but are not excessively toxic to normal cells.               Current cancer treatments – “cut, burn, poison” – are recognized as crude and painful. Promising new methods focus on delivering anticancer drugs precisely to the cancer (via monoclonal antibodies that respond to one type of protein on a cancer cell) and on increasing the immune system’s ability to fend off cancer ( 2004).   In all these, the nurses are responsible for co-ordinating care following any operations and/or treatment for breast cancer. As well as supporting the patients and his/her family through the operation and treatment, the nurses can provide the patient and his/her caregivers with clear written and verbal information; and can also examine the patient and arrange any tests that might be needed.   The NHS Cancer Plan, published in September 2000, sets out the first ever comprehensive strategy to tackle the disease. It is the first time any government has drawn up a major program of action linking prevention, diagnosis, treatment, care and research. The NHS Cancer Plan contains a wide range of targets and commitments. The NHS Cancer Plan Progress Report released in March 2005 substantial progress has been made in meeting the Plan’s targets. The thirty-four cancer networks which have been established have achieved important improvements in delivering cancer services across England ( 2005).   The progress report also mentioned that cancer networks have helped improve cancer services and have achieved some particular successes. These include planning for the introduction of new cancer drugs and developing plans for funding specialist palliative care. In addition to the NHS Cancer Plan, the Department has launched other initiatives to improve cancer services, including a tobacco advertising ban and a strengthening of the partnership between the NHS and the voluntary sector (2005).   There have been many largely anecdotal descriptions of the extreme psychological distress, social, and sexual difficulties associated with breast cancer treatment (, 1991). Numerous descriptions in the scientific literature and lurid accounts in the popular press continue to chart the psychosocial havoc wreaked by the diagnosis of breast cancer and its treatment, especially if that treatment involves breast amputation.   It is also important to remember that denial is a common and important coping strategy for many women with breast cancer. This is just a normal psychological process and what the nurse can do is to provide support.   For a woman who has already undergone many emotional and physical assaults, the news that she must now go through several courses of chemotherapy or other therapeutic procedures over a period of several months after being diagnosed of cancer is often regarded with a mixture of fear and suspicion. Just as the diagnosis of breast cancer has created denial and anxieties, the need for chemotherapy or other therapeutic procedure may create similar anxieties.   Women with breast cancer also has counselling needs which has to be taken cared of. The primary aim in counseling patients with breast cancer is to help women find their own means of coping with the emotional stresses of having a life-threatening illness. Coping is referred to as ‘constantly changing cognitive and behavioural efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person’ ( 1991). The outcome of good coping in this sense means successfully adapting to the difficult and changing physical and emotional demands placed on a woman with breast cancer.   Tremendous emotional upheaval is common after being diagnosed with cancer. Many cancer patients experience feelings disbelief, shock, fear, and anger. They may also feel overwhelmed by the girth of information about their cancer and their treatment options, by the decisions they are required to make, and by the sudden changes in their lives. It takes time to accept and understand the diagnosis. As overwhelming and painful as a diagnosis of cancer is initially, many cancer survivors say that their struggle against cancer gave them an opportunity to re-evaluate their lives and to find strengths and abilities that they hadn't known they possessed (, 2004).   The UK Department of Health abandoned the policy of advising women to examine their breasts in 1991 and the current advice to women is to be "breast aware". , director of cancer information at Cancer Research UK, said being "breast aware" meant looking out for changes such as a new lump or thickening in one breast or armpit, any puckering, dimpling or redness of skin, changes in the position or condition of the nipple and any new pain or discomfort felt on one side. In light of this, it is understandable that even if self-breast examination cannot really be effective, other means of breast examination can still be helpful.                                 References

LITERATURE REVIEW: CHILDHOOD IMMUNISATION

Literature Review 1. WHY IS CHILDHOOD IMMUNISATION IMPORTANT? The human body has the ability to resist almost all types of or...