Genetic Testing For Haemophilia Health And Social Care Essay

MFA presented to the day care of the Paediatric section with left mortise joint swelling for one twenty-four hours after hitting his mortise joint on a rock while playing in the flushing one twenty-four hours prior to admittance. There was hurting and bruising seen at the mortise joint articulation after the injury. The swelling increased in size and became more painful throughout the dark. His parents so brought him to the day care early the following forenoon. Physical scrutiny revealed swelling and tenderness at the left ankle joint every bit good as decreased scope of motion on both inactive and active motion due to trouble. There were besides multiple ecchymosis in different phases seen at the upper and lower limbs. A diagnosing of haemarthroses of the left mortise joint articulation was made. MFA was transfused with 200IU of Factor VIII. The hurting and puffiness were reduced in badness but persisted throughout the twenty-four hours. MFA returned to the day care the following twenty-four hours for more Factor VIII. He was given Factor VIII transfusion 200 IU twice daily for the following two yearss. The hurting and puffiness subsided after 3 yearss. MFA was diagnosed with terrible Haemophilia Angstrom when he was eight months of age. The diagnosing was made at the national blood bank. Familial testing besides done at the national blood bank revealed that his female parent was a haemophilia cistron bearer. MFA receives transfusion of Factor VIII when he develops haemarthroses or shed blooding due to trauma. He requires factor transfusion on an norm of one time every three months. He has had repeated hospital admittances with an mean continuance of stay for three to four yearss. MFA has good household support and is a member of the haemophilia society. He and his household have adapted good to his unwellness. Student Name: Tan Hai Liang ID NO: M0409146 Name OF SUPERVISOR: Dr Kyin ROTATION: PediatricssPATIENT ‘S DETAILSI/C NUMBER: ( B ) 630902-01-6092 Age: 9 old ages old Sexual activity: Male DATE OF ADMISSION: 23/04/09 R/N NUMBER: N/A2 ) CLINICAL HISTORYChief ailment: MFA is a nine twelvemonth old male child who was diagnosed with haemophilia A since eight months old. He presented with swelling in the left mortise joint for one twenty-four hours. History of present unwellness: MFA was running in the field at school when he knocked his mortise joint against a big rock in the land on the eventide of the twenty-four hours prior to showing at the day care. There was hurting after he hit his mortise joint but he was able to bear weight and walk. There was some bruising but no hemorrhage at the site of hurt. The joint became more painful towards the dark and there was some puffiness, heat and inflammation which increasingly increased. The hurting increased in badness so much so that MFA was unable to bear weight and used a wheelchair belonging to his brother to travel about the house. The hurting caused him some uncomfortableness but he was able to kip. He did non take any analgesia for the hurting. The following twenty-four hours, MFA ‘s parents brought him to the day care of the pediatric section for a factor transfusion. Systemic reappraisal was everyday. MFA was foremost diagnosed with haemophilia A when he was 8 months of age. His parents noticed that he developed contusions at his custodies and articulatio genuss. This occurred when he was tilting to creep. A blood trial was done in the national blood bank, and his parents were told that MFA had terrible hemophilia A. His immediate household underwent testing and his female parent was found to be a bearer of the haemophilia cistron. MFA receives factor VIII transfusion on an norm of one time every three months. The transfusions are required when he develops haemarthroses or gum hemorrhage due to tooth decay. The joint most normally affected is his right articulatio genus articulation. He has non developed any contractures. He does non normally seek medical intervention for contusions which are a common happening. He has non had mucosal shed blooding as nosebleed or hematuria. MFA would sometimes necessitate hospital admittance for factor VIII transfusion. This is normally when he has hemorrhage or terrible hurting due to a haemarthroses or a hematoma. At other times he would have the transfusion at the day care and return place. His parents would convey him once more to the infirmary for the following dosage till the hurting and puffiness in the joint resolutenesss. If a transfusion were required at dark when the day care is non unfastened, MFA would travel to the pediatric ward where the medical officer would be able to administrate the factor VIII. His symptoms would better with the factor VIII transfusion. MFA is an active male child who likes playing and running about. However his instructors in school restrict his physical activity to non-contact athleticss such as badminton and running. He is besides discouraged from unsmooth drama with his classmates. He wears elastic guards around his cubituss and articulatio genuss to protect them from hurt. However the elastic guards do non assist much as he still develops haemarthroses at those articulations. MFA is presently casting his decidual dentition. As such he requires factor VIII transfusion screen prior to tooth extraction. MFA is under followup at the pediatric clinic of Batu Pahat. He has defaulted the followup as his parents feel that nil much was done during the visits. He merely presents to the day care when necessitating factor VIII transfusion. MFA has besides been referred for physical therapy after episodes of haemarthroses which limit motion in the articulations. He has attended a few Sessionss of physical therapy in order to forestall contracture at articulations which have haemarthroses. He does non hold regular assignments. MFA is a member of the haemophilia society. His parents on a regular basis attend meetings where negotiations are given to educate parents on caring for haemophiliac kids. The members besides relate their experiences and promote one another. MFA has a medic qui vive necklace which says that he has haemophilia A. However, he rarely wears the medic qui vive. Past medical history MFA has non had any other infirmary admittances other than those due to haemophilia. Family history MFA is the youngest of three siblings. His senior sister is twenty old ages old and is good. His senior brother is 15 old ages old and has a bone cyst. He has undergone eight surgeries to mend the bone cyst every bit good as due to complications such as refractures. The wheelchair which MFA used at place was bought for his brother ‘s usage. MFA ‘s parents are good. There is no household history of hemophilia on his maternal side even though she is a bearer. MFA ‘s female parent has 3 brothers but all of them are good and do non hold hemophilias. There is no history of shed blooding upsets in the household. Social history MFA ‘s parents are both instructors. However they have to lose traveling to work frequently due to MFA ‘s status which necessitates frequent visits to the infirmary. As such, MFA ‘s female parent has a particular agreement with her schoolmaster which allows her to learn from 11 to 4 autopsy. As such, she is free in the forenoon to convey MFA to the infirmary when he needs it. His parents besides provide good support for MFA in that they frequently attend haemophilia meetings to update themselves on agencies to outdo attention for their kid. Birth history MFA was born at term in Hospital Batu Pahat. He was delivered through an elected cesarean delivery subdivision due to a breech presentation. There were no prenatal abnormalcies detected during everyday prenatal medical examination. There were no perinatal or station natal complications. He was nursed with his female parent after birth and discharged uneventfully. Developmental history MFA is presently in primary three of a spiritual school. He is an above mean pupil who finishes in the top 10 of his category. His instructors have no ailments about his school assignment. Developmental mileposts prior to this were all achieved at the appropriate times. Dietary history MFA is on an grownup diet now. He eats balanced repasts which are normally prepared by his female parent. He was breastfed till the age of seven months. Weaning was with porridge at the age of five months. Immunization history MFA has been immunized harmonizing to the immunisation agenda. After he was diagnosed with hemophilia A, his immunisations were done at the pediatric clinic under factor VIII screen. His last immunisation was at seven old ages of age. Student Name: Tan Hai Liang ID NO: M0409146 Name OF SUPERVISOR: Dr Kyin ROTATION: Pediatricss3 ) Findings ON CLINICAL EXAMINATIONOn general scrutiny, MFA was friendly and communicative. He was sitting in a wheelchair with a patch around his left mortise joint. There were some ecchymosis seen at his weaponries and thighs. He looked good nourished. He was non in terrible hurting. Anthropometric measurings: Weight: 24kg ( 10th to 25th centile ) Height:130cm ( 25th to 50th centile ) His critical marks were normal: Pulsation: 82 beats per minute Respiratory rate: 18 breaths per minute Blood force per unit area: 108/72 Temperature: 37 grades Celsius Examination of the lower limbs: There were ecchymosis seen on both lower limbs at the thigh every bit good as at the shin and calf. The left mortise joint was swollen and there was a contusion seen on it. It was stamp on tactual exploration but there was no addition in temperature. There was reduced motion of the left mortise joint articulation due to trouble. The right mortise joint articulation every bit good as both the left and right articulatio genus articulations were normal. There were no contractures seen. Examination of the upper limbs: There was besides some contusions seen on both the upper limbs. The cubitus and wrist articulations were normal on both custodies. The scope of motion for all the articulations on both upper limbs were normal. Examination of the cardiovascular and respiratory systems every bit good as scrutiny of the venters was normal. Student Name: Tan Hai Liang ID NO: M0409146 Name OF SUPERVISOR: Dr Kyin ROTATION: Pediatricss4 ) PROVISIONAL AND DIFFERENTIAL DIAGNOSES WITH REASONINGProbationary diagnosing: Haemarthroses of the left mortise joint articulation — — Evidence for: MFA has been diagnosed with hemophilia since the age of eight months. The articulations are a common site of shed blooding for hemophiliac. In add-on, MFA has had anterior episodes of hurting and puffiness in the joint similar to this episode. The hurting reduced when he was given factor VIII transfusion which farther supports this diagnosing. He besides has multiple contusions on his weaponries and legs which indicate that he has a hemorrhage upset. Differential diagnosing: 1 ) Juvenile Rheumatoid Arthritis The pauciarticular type of juvenile rheumatoid arthritis nowadayss with hurting and puffiness in the big articulations such as articulatio genuss, mortise joints and carpuss. It may show as symmetrical arthralgia or may merely impact one articulation. Evidence against: Juvenile rheumatoid arthritis normally nowadayss during childhood while MFA has been holding episodes of joint hurting and puffiness since he was an baby at eight months of age. Juvenile arthritic arthritis is besides associated with forenoon stiffness which MFA does non hold. MFA besides has easy contusing which is non a characteristic of juvenile rheumatoid arthritis 2 ) Septic arthritis Patients with damaged articulations are predisposed to infected arthritis. As such, a haemophiliac patient who has repeated haemarthroses may hold damaged articulations which are susceptible to infection. Evidence against: Patients with infected arthritis normally have fever while MFA did non. They are besides more common in patients who are immunocompromised. On physical scrutiny, there was no increased heat in the joint which would be more declarative of infected arthritis. 3 ) Ankle ligament hurt A sudden turn of the mortise joint may do a wrenching of the soft tissue and ligaments around the mortise joint doing hurting and puffiness. Evidence against: Master of fine arts did non writhe his mortise joint while playing. He simply knocked it against a stone. As such the mechanism of hurt does non propose that the ligaments were strained. He was besides able to bear weight after hitting his mortise joint and the puffiness and hurting bit by bit developed. This is contrary to what is expected in a sprained mortise joint where there would be immediate puffiness and hurting around the mortise joint. Student Name: Tan Hai Liang ID NO: M0409146 Name OF SUPERVISOR: Dr Kyin ROTATION: Pediatricss5 ) IDENTIFY AND PRIORITISE THE PROBLEMS1. Swelling at the left mortise joint MFA has hurting and puffiness at the left mortise joint articulation. He was in moderate hurting which he rates as 6 out of 10 on the hurting mark. Analgesics such as acetylsalicylic acid and NSAIDS are non recommended for him as they cause shed blooding in hemophiliac. As such the best agencies for rapid alleviation of the hurting and the swelling would be Factor VIII transfusion. 2. Hazard of joint devastation MFA is presently eight old ages old and is an active male child who enjoys playing with his friends. As such he is prone to injury from even mild injury. He has developed haemarthroses on an norm of every 3 months. Perennial haemarthroses at the same articulation could do devastation of his articulations taking to osteoarthritis, restriction in motion and development of contractures. A hold in intervention could besides do harm to the joint. As such, prompt and equal factor VIII transfusion is indispensable for MFA. He should besides be referred to the physical therapy section when the hurting has subsided. Physiotherapy would assist in forestalling the development of joint contractures 3. Hazard of shed blooding Due to his active nature, MFA is besides at hazard of terrible hemorrhage if he injures himself. He was last admitted to the infirmary for one hebdomad due to shed blooding when he fell while playing. There was terrible hemorrhage from his oral cavity and gums when he hit his face on a tabular array. MFA is besides presently casting his decidual dentition. As such, he is at hazard of gum hemorrhage from the site of tooth extraction. The most unsafe hazard is that of an intracranial bleeding 4. Hazard of perennial factor transfusions MFA requires frequent factor transfusion. As the factor VIII used in Batu Pahat is derived from human plasma, there is a hazard that MFA may acquire Hepatitis B, Hepatitis C or HIV infections. In add-on, MFA has non been screened for any of these infections. As such it is necessary for MFA to be screened as recommended by the Malaysian protocol for the direction of hemophilia. 5. Consequence of unwellness on school assignment and day-to-day activity MFA misses school for about a hebdomad on an norm of one time every three months. This may impact his public presentation in school. In add-on there is an addition demand for him to acquire good academic consequences as he would necessitate to believe about a hereafter with a calling that does non necessitate heavy physical activity due to his status. Trouble faced by caretakers MFA ‘s male parent and female parent are both working and frequently are forced to lose work in order to take attention of MFA when he develops episodes of hemorrhage. Both the parents are instructors who have understanding schoolmasters who sympathize with them and give them much leeway in order to care for their kid. However the uninterrupted emphasis of taking attention of a inveterate sick kid demands to be addressed. Support groups such as the haemophillia society would be able to assist the parents by giving them entree to other parents who face similar troubles. These parents would be able to promote one another and portion tips on caring for haemophilliac kids Student Name: Tan Hai Liang ID NO: M0409146 Name OF SUPERVISOR: Dr Kyin ROTATION: Pediatricss6 ) Plan OF INVESTIGATION, JUSTIFICATIONS FOR THE SELECTION OF TESTS OR PROCEDURES, AND INTERPRETATION OF RESULTSProbes done at 8 months of age by the national blood bank: 1. Curdling profile Justification: MFA presented with peliosis at his limbs which indicates that might hold a hemorrhage upset. As such a curdling profile would be utile to see if the curdling tracts are affected. Consequences: APTT prolonged. More than 90 seconds Interpretation: The drawn-out APTT indicates that the intrinsic tract is affected and that one of the factors in the intrinsic tract may be deficient. 2. Serum factor VIII degree Justification: To determine which specific factor that is lacking doing the hemorrhage upset. Consequences: Factor VIII degree: 0.6 % ( No inhibitors detected ) Interpretation: MFA has severe haemophilia A due to his Factor VIII degree being less than 1 % . He will react to factor VIII transfusion as there are no inhibitors to factor VIII detected. No probes were done for this presentation at the day care. I would propose the undermentioned probes: 1 ) A field radiogram of the ankle articulation AP and sidelong position Justification: In order to govern out other causes of the joint hurting such as infected arthritis or break at the joint. Possible grounds why it was non done: The clinical presentation of the patient did non propose that he has infected arthritis as he did non hold a febrility and the articulation was non ruddy. As the clinical image was typically implicative of a haemarthroses given that he is a hemophiliac, it would be unjust to the patient to subject him to an ten beam as this would intend he would be exposed to radiation every three months. 2 ) Full blood count Justification: A full blood count would be utile to see if there is an increased white cell count which may bespeak an infection. Possible grounds why it was non done: MFA is clinically good with no symptoms of infection such as febrility. As such a full blood count may non be necessary as it would likely be normal. There is besides a hazard of shed blooding or hematoma from venepuncture. Student Name: Tan Hai Liang ID NO: M0409146 Name OF SUPERVISOR: Dr Kyin ROTATION: Pediatricss7 ) Working DIAGNOSIS AND PLAN OF MANAGEMENT ON ADMISSIONWorking diagnosing: Haemarthroses of the left mortise joint due to Haemophilia A My proposed program of direction: I ) Factor VIII transfusion with a mark serum factor degree of 30 % eight hourly till the puffiness and hurting resolutenesss two ) Elastic patch and ice battalion around the left mortise joint three ) To rest the mortise joint articulation by non-weight bearing boulder clay swelling and hurting reduces four ) To analyze patient for joint malformation or contractures prior to dispatch from day care V ) Refer the patient to physiotherapy for joint rehabilitation of the affected articulation. six ) To educate the parents on attention for their kid and protective steps to forestall hurt. Student Name: Tan Hai Liang ID NO: M0409146 Name OF SUPERVISOR: Dr Kyin ROTATION: Pediatricss8 ) Summary OF INPATIENT PROGRESS ( INCLUDING MAJOR EVENTS, CHANGE OF DIAGNOSIS OR MANAGEMENT AND OUTCOMES )MFA was given 200 IU of Factor VIII transfusion. He was so asked to return the following twenty-four hours to be reviewed by the medical officer in charge. Merely one transfusion was deficient for the puffiness and MFA had to digest much uncomfortableness and hurting throughout the dark. This is despite the Malayan Paediatrics protocol recommendation that factor VIII is given every 8 to 12 hours. The ground for this could be the prohibitory cost of the factor. The following twenty-four hours MFA was given another 200 IU of Factor VIII transfusion in the forenoon and once more in the eventide, 12 hours apart. He was given two more transfusions on the 3rd twenty-four hours. The transfusions were given at the day care in the forenoons and at the pediatric ward at dark by the medical officer who was on call. The hurting and swelling resolved on the 4th twenty-four hours post hurt. He was examined by the medical officer and was told to merely return to the day care if he had another episode of joint puffiness or open hemorrhage. Student Name: Tan Hai Liang ID NO: M0409146 Name OF SUPERVISOR: Dr Kyin ROTATION: Pediatricss9 ) DISCHARGE PLAN, COUNSELLING AND MOCK PRESCRIPTIONDischarge program: I ) MFA was asked to rest him left mortise joint and to partly bear weight till it was wholly pain free. two ) Referral to the physical therapist for joint rehabilitation to be done Guidance: I ) MFA was advised to avoid athleticss which involve physical contact as the even minimum injury may do a bleed. two ) MFA ‘s parents were told to convey him back to the day care if there were any longer episodes of shed blooding into the articulations or self-generated hemorrhage. They were given a eventuality program to travel straight to the pediatric ward and see the medical officer on call if any hemorrhage were to go on when the day care is closed. three ) MFA and his parents were besides educated on complications that they need to look out for such as intracranial bleeding. They were taught about the marks and symptoms that they should be wary of. four ) MFA was encouraged to travel for physical therapy which he had antecedently defaulted. He was told about the dangers of joint devastation due to recurrent haemarthroses and how physical therapy may help in forestalling contractures. Student Name: Tan Hai Liang ID NO: M0409146 Name OF SUPERVISOR: Dr Kyin ROTATION: Pediatricss10 ) REFERRAL LETTER ( MANDATORY )Dr Tan Hai Liang, Paediatric Department, Hospital Batu Pahat Physical therapist, Physiotherapy section, Hospital Batu Pahat 27 May 2009 Dear sir, Patient ‘s name: Mohammad Faiz Affizuddin Patient ‘s I/c figure: ( B ) 630902-01-6092 Problem: Haemarthroses of the left mortise joint articulation Thank you for seeing this nine twelvemonth old male child who was diagnosed with Haemophilia A for the past eight old ages. He has had recurrent episodes of shed blooding into the articulations. The articulations most normally affected are the articulatio genus articulations and elbow articulations. His current presentation is for a haemarthroses of the left mortise joint articulation. Physical scrutiny: Inflammation and puffiness of the left mortise joint articulation. Tenderness on tactual exploration. Reduced scope of motion both active and inactive. He has been given Factor VIII transfusion which has reduced the puffiness and hurting. Kindly reexamine the patient and execute joint rehabilitation for him. He has good household support and his household could besides be taught exercisings to forestall joint contractures that can be done at place in position of his recurrent shed blooding into the articulations. Thank you. Yours genuinely,______________( Dr Tan Hai Liang ) Student Name: Tan Hai Liang ID NO: M0409146 Name OF SUPERVISOR: Dr Kyin ROTATION: Pediatricss11 ) Learning ISSUES IN THE 8 IMU OUTCOMES1 ) Family and community issues in health careHow are parents affected by holding a hemophiliac kid? I had the chance to speak to MFA ‘s parents and inquire them about the challenges faced when caring for him. They related many of their experiences and confided that many alterations to the life style of the household were done in order to accommodate to populating with and caring for a hemophiliac. Both parents have had to lose work on a regular basis due to MFA ‘s frequent infirmary admittances. Family activities besides are limited to light physical activity with minimum hazard of hurt. Furthermore MFA ‘s female parent admitted to ab initio experiencing guilty as she was the bearer of the cistron that leads to his status. As such, I wondered if hemophilia had an impact on parent ‘s quality of life in visible radiation of the many accommodations that they had to do to their life style. A survey by Beeton et al [ 1 ] involved 12 parents of kids with hemophilias whose age ranged from 18 months to 16 old ages of age. The parents were interviewed and qualitatively assessed on their experiences in caring for a kid with hemophilia. It found that medical direction often focused on assisting the hemophiliac adjust to his or her status with small accent on the wider household web. The early old ages of the kid ‘s life after diagnosing were characterized by the parents missing experience and feeling uncertain. This is coupled with the frequent demand of factor transfusion and the associated trouble in venous entree in babies and immature kids. Quality of life at the early old ages post diagnosing was found to be hapless due to parents experiencing ‘out of control ‘ . Parents caring for a hemophiliac kid besides reported that the manner in which they engaged with the people around them had changed. There was a necessity in being more self-asserting in order to protect their kid. This was confirmed by MFA ‘s female parent who relates that she had statements with the infirmary manager and schoolmaster of MFA ‘s school in order to take a firm stand on particular steps to be put into topographic point to better MFA ‘s quality of life. The survey besides found that female parents normally took up a greater duty in caring for the kid. Fathers who were at work during the twenty-four hours did non hold the same degree of experience and this could be a beginning of struggle between parents. Parents were besides found to hold higher degrees of emphasis and anxiousness. However the degree of the emphasis and anxiousness was dependent upon on the phase that parents had achieved in pull offing the status every bit good as successful version. Another survey by Bullinger et al [ 2 ] showed that the quality of life for patients and households with hemophilia was higher when compared to patients with other chronic unwellnesss such as asthma. This shows that households with hemophiliac are able to populate a comparatively normal life with good quality of life if certain stairss were taken to accomplish successful version. The survey found that betterment in quality of life can be attained by supplying an environment in which patients and parents experience understood and good informed. In decision, I learned that hemophilia has a profound consequence, non merely on the kid who has the disease but besides on his primary caretakers which are his parents. As such I need to besides ask about how parents are get bying and offer professional aid such as reding if necessary.2 ) Critical thought and researchIs coagulating factor dressed ore prophylaxis effectual in the direction of patients with hemophilias?A paper by Ljung [ 3 ] proposed that direction of a patient with hemophilia should travel off from concentrating on the upset itself and alternatively look towards keeping a healthy kid. This means that patient ‘s should non be repeatedly managed with factor transfusions when they present with shed blooding but alternatively be kept healthy by forestalling the hemorrhage from go oning in the first topographic point. As such the writer proposed that primary contraceptive therapy should be the gilded criterion in the direction of patients with hemophilias. However is coagulating factor dressed ore prophylaxis effectual in pull offing patients with hemophilias, and what are the associated factors which prevent this direction from being a practical option? I looked at a Cochranre reappraisal by Stobart et Al [ 4 ] which analysed four separate surveies affecting 37 patients. The consequences of the reappraisal showed that there was a statistically important difference in the decrease of shed blooding episodes in patients who were given standard prophylaxis when compared to a placebo. It besides found that secondary results such as clip loss to school and employment due to the unwellness was statistically significantly reduced among those having primary prophylaxis compared to a placebo. The reappraisal besides quoted one survey which showed that a twice hebdomadal extract of higher dosage of factor dressed ore had a statistically important advantage in cut downing the figure of bleeds a twelvemonth when compared to a lower dosage and less frequent disposal of transfusion. However the writers concluded that there was deficient grounds from randomized control tests to urge the usage of primary contraceptive factor extract in the direction of patients with hemophilias. An independent retrospective survey by Khoriaty [ 5 ] showed that primary prophylaxis has some promise. The survey recruited 133 patients with Haemophilia A and B with a average age of 27.93. It compared the 91 patients who were on primary prophylaxis and the staying 42 patients having on-demand intervention when they developed shed blooding. The survey found that there was a statistically important decrease in the figure of self-generated shed blooding per twelvemonth. Patients on primary prophylaxis were found to hold 3.2 bleeds per twelvemonth while those who received on-demand therapy bled 5.7 times per twelvemonth. It found no statistical difference between the two groups in footings of hemorrhage after injury. However the consequences for this survey needs to be read with attention due to the big age scope. Further surveies need to be done for the pediatric age group due to differences such as a higher leaning for injury and hurt in active kids compared to grownups who are better at caring for themselves. One ground why primary prophylaxis is non used in the intervention of haemophiliacs despite its promise is the high cost of the factor VIII. One phial of 200 IU costs in the part of RM 800. As such it may non be cost effectual for primary prophylaxis to be carried out particularly in the context of the Malaysian health care system with its limited budget. A cost effectivity analysis by Miners et al [ 6 ] in England showed that it would be & amp ; lb ; 547 to forestall one episode of shed blooding from go oning. This cost is mostly prohibitory in the Malayan context. In decision I found that there is grounds that primary prophylaxis has much promise in the bar of shed blooding among haemophilia patients but extra surveies need to be carried out particularly in the local environment in order to determine the cost-effectiveness of primary prophylaxis.3 ) Self directed life long larningWhat is the hereafter in footings of direction of hemophilia? The direction of hemophilia is presently with factor transfusions which aim to halt hemorrhage when it has already happened. The other option is primary prophylaxis with regular factor extracts to forestall hemorrhage. However this attack is dearly-won and does non cover with the job of patients developing inhibitors which make transfusions uneffective. As such, research workers are looking into a agency for a remedy of hemophilia. This remedy is by utilizing cistron therapy. The aim of cistron therapy is to redact a faulty cistron sequence to accomplish complete reversion of disease phenotype in the life-time of the patient. Haemophilia is seen as the ideal campaigner for cistron transportation therapy as foremost there are many cell types which are able to synthesise biologically active coagulating factor. Second, there is a broad remedy window which makes it unneeded to hold rigorous cistron look. Third there are big and little animate being theoretical accounts that permit the survey of safety and efficaciousness prior to induction of human tests. [ 7 ] Phase 1 clinical tests are presently being done utilizing largely viral vectors to infix the cistron. Retroviruss have shown promise in this therapy. The cistrons are inserted via developing hepatocytes or hematopoietic root cells. Presently safe long term look of coagulating factors has been successfully achieved in big carnal theoretical accounts of hemophilias utilizing multiple cistron transportations. [ 8 ] Gene transportation therapy nevertheless still faces many obstructions before it can be seen as a feasible therapy for hemophilia. There is hazard of experimentation in worlds in order to formalize this therapy. Many inquiries besides remain unreciprocated such as inhibitor development after the interpolation of the cistron and besides the transmittal of the extra cistron to the kids of the patient who receives the cistron therapy. One paper suggested a generous timeline of at least 20 to 30 old ages before the potency of cistron therapy can even be considered. These issues are ‘merely medical ‘ issues. Religious and ethical issues besides have to be taken into consideration before prosecuting this direction. In decision, I learned that though there is much potency in this field of cistron therapy, much research still has to be undertaken to determine its safety every bit good as efficaciousness. However it has been a valuable experience in larning about new modes of intervention and to catch a glance of what the hereafter holds. This has taught me to go on larning as there are ever new sentiments and therapies available in the direction of any unwellness. 4 ) Professionalism, moralss and personal development What are the ethical deductions of familial proving for haemophilia? After MFA was diagnosed with haemophilia, his immediate household underwent familial testing. The proving revealed that his female parent was a bearer and that his senior brother and senior sister were normal. The familial testing was done voluntarily. There is no recommendation in the Malayan Paediatric protocol for familial testing to be done. Familial testing is normally done in patients with no clear household history in order to determine which parent is a bearer so that farther stairss of direction can be carried out. These farther stairss may include offering familial testing to the siblings of the bearer parent and besides reding about hazard of holding extra kids. However familial testing besides raises many ethical inquiries. First there is guilt, heartache and ego incrimination when a female parent with no known household history of hemophilia discoveries that she was the cistron bearer that passed it on to her kid. A paper by Thomas et al [ 9 ] on attitudes towards familial proving in an Australian community found that female parents who were ‘sporadic ‘ bearers ( no known household history of hemophilia ) were had feelings of guilt. Performing familial testing to determine that a female parent of a haemophiliac kid is a bearer would merely be of value if extra stairss were taken such as offering familial testing to the female parent ‘s siblings. This in itself would raise inquiries of confidentiality and revelation since offering the testing would necessitate the physician to unwrap to the other household members that the female parent is a bearer. This revelation could so take to stigmatisation. In this specific instance, MFA ‘s female parent was found to be a bearer. She related that she felt anguished at ‘causing ‘ her boy to endure much hurting. The cognition that the female parent was the bearer who had passed on the cistron to her boy did non change the direction of MFA. As such there was small virtue in executing the familial testing in this instance. A 2nd consideration of familial testing is the deductions that it has on a individual ‘s determination of whether or non to hold kids. This is once more more relevant for female bearers. Carriers should be counseled that there is a 50 per centum opportunity that their kid would hold hemophilias if he were a male child. However the ethical issue arises when there is no agency of correlating between the genotype and phenotype. [ 10 ] Just because the kid may hold hemophilia does non foretell the grade of badness of the hemophilia. The lone means to cognize for certain about the position of a foetus in footings of whether he would hold hemophilias and the grade of badness is by making antenatal familial proving such as chorionic villi sampling. Prenatal familial proving itself is associated with many ethical issues such as the deductions of transporting out such a trial. Would the foetus be terminated? There is legal leeway for expiration if it can be proven that the kid ‘s unwellness would convey about mental hurt to the female parent. Where do we pull the line to make up one's mind that such a foetus has excessively terrible a haemophilia so as to justify expiration? Who makes the determination? In the instance of MFA, the parents decided non to hold any more kids due to the hazard of holding another hemophiliac kid. It ca be seen that the familial testing had a profound impact on their determination. However proper and thorough familial guidance was non given to the parents. In decision I learned that familial proving for hemophilia is fraught with many ethical considerations. It should merely be offered when proper followup such as guidance, support and options can be offered to those undergoing the trial. In the absence of proper model of support, it may be better to keep back familial testing.