Novel Use of Endoscopic Ultrasound to Manage Complication of a Percutaneous Gastrostomy Tube Placement

Introduction

Percutaneous gastrostomy feeding tube placement (PEG tube) is a fairly common procedure performed in hospitals by Interventional Radiologists, Surgeons and Gastroenterologists. Complications such as bleeding, infection albeit rare are some of the potential immediate complications of a PEG tube placement. A more feared complication of a placement of a PEG tube is placement through another organ such as the colon or liver. We describe a case whereby Endoscopic Ultrasound (EUS) was used to manage such a complication.

Case

A 78 year-old female with no significant past medical history was admitted to an outside hospital for management of chronic dysphagia, weight loss, and failure to thrive. Although vital signs were normal, physical examination was notable for a thin elderly cachectic appearing female. To address her dysphagia and failure to thrive, she underwent percutaneous endoscopic gastrostomy (PEG) placement. Although mild pain and tenderness may be expected one day after PEG placement, the patient reported abnormally significant pain requiring further evaluation. Therefore, a computed tomography scan was performed reporting transection of the PEG through the left lobe of the liver (Figure 1a). It was decided after discussion to transfer the patient to a tertiary care center. Once the patient was transferred, she was deemed to be high risk for any surgical intervention given her cachectic and malnourished state. Interventional Endoscopy was consulted for consideration of endoscopic removal. After discussing risks/benefits with family of endoscopic removal as well as considering risks of surgical removal, it was decided to proceed with endoscopic removal. After sedation and intubation, a linear echoendoscope was passed to her stomach to visualize the liver. Endoscopic ultrasound confirmed liver transection; however, no major hepatic blood vessels were traversed (Figure 1b). Doppler flow was used to confirm lack of vascular penetration. Since the risk of hematoma development after PEG tube removal was likely low, it was deemed appropriate to proceed with PEG tube removal.

After removal of the echoendoscope, the external portion of the PEG tube was cut (Figure 1c). An upper endoscope was then passed and the internal bumper and the remainder of the shaft of the PEG tube was removed with the help of a snare. Next, the resulting fistulous tract was closed with an over-the-scope clip (Ovesco, 11/6, Germany) (OTSC) (Figures 1d & 1e). The linear echoendoscope was then re-introduced where the liver was reassessed. No obvious evidence of bleeding or hematoma was found on EUS. Finally, the scope was removed, and the external defect was left to heal by secondary intention. The next day, the patient reported resolution of abdominal pain and no leakage was found on inspection. Hemoglobin remained stable. Despite the successful outcome of the procedure, the patient was transitioned to comfort care for reasons unrelated to the EUS-guided PEG tube removal.

Figure 1

Discussion

Percutaneous endoscopic gastrostomy (PEG) placement is a common procedure with multiple indications from chronic dysphagia to nutritional support. However, complications can occur including leakage, bleeding, fistula formation, and more [1]. Transection of the liver is a rare complication with one study documenting seven total cases reported in literature [2]. Although abdominal pain may be the most common symptom, other symptoms may include fever, nausea, transaminitis, PEG tube malfunction, or even no symptoms [2-7]. Prompt diagnosis by ultrasound or CT scan is imperative to confirm liver transection. Although laparotomy and conservative management were the most common reported treatments, Endoscopic Ultrasound (EUS) guided evaluation may provide an effective alternative for management of PEG tube-related liver transections [2]. Since the implementation of EUS in gastroenterology, advanced endoscopists have discovered creative methods to improve patient outcomes while avoiding unnecessary surgeries. This case highlights an unfortunate rare complication from PEG tube placement. However, endoscopy could play a role in safely removing the PEG tube from the transected liver while closing the defect internally. In our case, EUS was initially used to evaluate if any hepatic blood vessel was traversed. If the EUS recognized a traversed blood vessel, the risk of hemorrhage or hematoma formation would be high if the PEG tube was to be removed endoscopically and alternative management would be warranted.

In such scenario, removal of PEG tube should be performed in Interventional radiology suite or the Operating Room with standby assistance from interventional radiologist or surgeon respectively. Fortunately, this patient had no traversed blood vessel; therefore, it was deemed appropriate to remove. Second, given that the PEG tube was traversing the liver, external removable would simply result in more trauma to the liver. Hence the tube was cut, and the internal bumper retrieved endoscopically, thereby achieving an atraumatic removal of the PEG. Once the PEG tube was removed, the gastro-hepato-cutaneous tract would need to be addressed. Over-the-scope clips (OTSC) are emerging endoscopic devices growing in popularity. They have been successfully used to close large ulcers, perforations, and fistulas [8]. To prevent the risk of leakage or fistula formation, an OTSC was successfully deployed. Lastly, once the PEG tube is removed and the OTSC placed, EUS was performed to help confirm any intra-hepatic/ extra hepatic bleeding or expanding hematomas that may require further intervention. As EUS becomes more accessible, the field will require more creative approaches regarding its use. This case provides a creative way to implement EUS after a PEG complication. By anticipating potential complications with removing the PEG, EUS was used to locate potential blood vessels that may have been traversed. Therefore, EUS evaluation provided safe PEG removal knowing the bleeding risk was likely low. Endoscopic ultrasound has many therapies to offer; however, future documentation of unusual cases will help providers identify opportunities for its potential use.

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Intestinal Resection for Mesenteric Panniculitis

Clinical Image

We report the case of a 61-year-old woman, with no past medical or surgical history, who consulted for an occlusive syndrome. On examination, she had no fever; her abdomen was distended and showed subumbilical tenderness. Laboratory tests revealed a marked biological inflammatory syndrome. Abdominal CT revealed a distended small bowel upstream of a regular thickening of the last ileal loop which showed an enhancement defect, densification of the mesenteric fat with distortion of the vessels within it and a comb-like appearance of the mesentery suggestive of mesenteric panniculitis (MP) (Figure 1). The patient underwent urgent surgery. Intraoperatively, there was diffuse nodular thickening of the mesentery; sclerolipomatosis; a necrotic last ileal loop with a highly inflammatory aspect of the penultimate loop (Figure 2). She underwent ileocaecal resection, removing the pathological loops with a double stoma (Figure 3). The postoperative follow-up was simple. Pathological examination of the surgical specimen revealed mesenteric lipodystrophy and patchy fibrosis without carcinomatous cells, confirming the diagnosis of MP. Mesenteric panniculitis is a rare chronic inflammatory disease characterized by degeneration, inflammation and fibrosis of the adipose tissue of the mesentery.

Figure 1

Figure 2

Figure 3

The etiology of the disease remains poorly understood, but it is often associated with a variety of conditions, including abdominal surgery, mesenteric ischemia, cancer, trauma, obesity and abdominal inflammatory disease [1]. Abdominal CT are essential for both positive and differential diagnosis [2]. Surgery is indicated to treat obstructive complications and served for histological diagnosis [1].

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Intercalary Allograft Reconstruction using 3D Designed, Patient-Specific Surgical Guides and Plate during Resection of Primary Malignant Bone Tumors: Workflow and Surgical Technique

Introduction

En-bloc resection of primary malignant bone tumors potentially results in large segmental bone defects. Massive bone allografts have been used for reconstruction and limb salvage after tumor resection, as alternative for endoprostheses. Allograft reconstruction of metaphyseal bone defects can be used to preserve the adjacent joint1. Technical challenges can result in a poor fit of the allograft, suboptimal positioning of the plate, inadequate resection margins, and malpositioning of screws. Furthermore, allograft reconstructions have been associated with complications such as pseudo-arthrosis of host-allograft interface, infection, allograft fracturing or implant breakage [1]. Advancements in imaging modalities and 3D-technology can contribute to improve geometric alignment between allograft and host bone and reduce mechanical complications. Based on Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) and Computer Aided Design and Manufacturing (CAD-CAM) techniques, a 3D Virtual Surgical Plan (VSP) can be made, in which the exact margins of the tumor are delineated and osteotomies with adequate margins for resection are planned. Patient-specific surgical guides with incorporated screw pilot holes can be used to translate a VSP into the actual operation. 3D technology can be used to create a custom plate and pre-determine the length and position of screws, which is helpful to achieve the optimal fit and stability of the allograft reconstruction [2,3]. We demonstrate the technique of allograft reconstruction using 3D-printed surgical guides and a custom-made osteosynthesis plate after resection of a primary malignant bone tumor. We describe our workflow on the basis of a patient with telangiectatic osteosarcoma of the tibia.

Surgical Technique

A 35-year-old man without significant medical history, visited our orthopedic outpatient clinic with pain at the anterior aspect of the lower leg, which existed for three months. Physical examination revealed a solid swelling (5x4cm) on the anteromedial aspect of the tibia. There was a full range of motion of both knee and ankle joint. Plain radiographs demonstrated a radiolucent zone on the medial aspect of the proximal tibia diaphysis, cortex irregularity and soft tissue swelling (Figure 1). An MRI with intravenous gadolinium contrast revealed an intra-osseous lesion with extra osseous expansion, extensive cortex destruction and liquid levels within the tumor (Figure 2). Dorsal neurovascular structures were not involved in the tumor. The length of the intramedullary mass measured 12,4 cm. The distance between tumor and knee joint space was 35mm. A biopsy was performed. Histologic examination demonstrated telangiectatic osteosarcoma. Further diagnostic work-up (PET-CT) revealed no metastasis. After three cycles of neo-adjuvant chemotherapy with doxorubicin and cisplatin, operative treatment was scheduled. Due to the anticipated large bone defect and the tight margin to the tibia plateau, it was decided to perform a knee -sparing procedure using 3D planned resection guides and allograft reconstruction with a patient-specific titanium osteosynthesis plate.

Figure 1

Figure 2

3D Virtual Surgical Planning

Using the preoperative CT and MRI, a 3D VSP was made. The resection margins, based on MRI tumor delineation, were planned and an allograft was ordered according to the planned defect size (Figure 3). A safe margin of 10 mm to the delineated tumor was planned. The allograft was CT-scanned and incorporated in the VSP. Screw positions were planned in both the proximal, distal and allograft segments and a patient-specific osteosynthesis plate was designed. Surgical guides were designed for both the patient and allograft, to accurately translate the planned osteotomies and screw pilot holes to the surgical procedure. A dome-shaped osteotomy below the tibia plateau was planned for the proximal cut in order to create surface enlargement aiming to lower the risk of non-union. This also minimizes movement in medio-lateral direction at the contact site. Using the surgical guides and a custom osteosynthesis plate, we were able to plan five screws in the proximal tibial remnant. Using off-the-shelf osteosynthesis we would not have been able to spare the joint due to a lack of screw possibilities and subsequent instability of the osteosynthesis. Within five days, the plate was milled from medical grade 23 titanium by a local ISO 13485 certified manufacturer (Witec Medical, Stadskanaal, The Netherlands). Screw threads matching 3.7mm Synthes locking screws were incorporated in the plate. Meanwhile, the surgical guides were 3D printed from medical grade polyamide powder (Oceanz, ISO 13485 certified, Ede, The Netherlands). All materials were received in-house and sterilized within a week from the VSP start. The described 3D VSP workflow necessitates a multidisciplinary approach including technical expertise of a skilled technical physician, engineer, and orthopedic and plastic surgeon.

Figure 3

Intraoperative Technique

A longitudinal midline incision was made on the anteromedial side of the lower leg with resection of the biopsy mark. The soft tissue mass was exposed and isolated. The medial gastrocnemius muscle was mobilized for later flap coverage. Then the custom-made surgical guide was placed on the tibia to determine the proximal and distal resection planes and screw pilot holes (Figure 4). The fitting and shape of the patient-specific guide was tailored to the contour of the tibia. The multiplanar proximal cut is located 1 cm under the tibia plateau. The distal cut was orientated perpendicular to the tibia shaft. Simultaneously, the allograft tibia with patellar tendon was prepared with its own surgical guide that indicated corresponding resection planes with the tibia and pre-drilled screws holes (Figures 5 & 6). On the lateral aspect of the allograft, a gutter was created for placement of the ipsilateral vascularized fibula graft at a later stage. The tumor was resected and the segmental defect in the tibia (length: 13 cm) was reconstructed by the allograft (Figure 7). The custom-made plate was used to fixate the graft (Figures 8 & 9). The screw holes in the plate corresponded with the exact localization and trajectories of the pre-drilled screw holes in the allograft. A separate lateral incision was made to harvest the vascularized fibula graft with accompanying flexor hallucis longus muscle. The fibula was transferred into the lateral gutter of the allograft (Figure 10). Hereafter the patellar tendon was reconstructed with non-absorbable sutures and the plate was covered with the medial gastrocnemius muscle flap. The muscle was covered with a split skin graft from the contralateral upper leg. A cast in extension was applied, non-weight bearing during the first 6 weeks. Hereafter, a flexion-extension brace was applied with gradual increased flexion (two weeks 0-30°, two weeks 0-60° and two weeks 0-90°).

Figure 4

Figure 5

Figure 6

Figure 7

Figure 8

Figure 9

Figure 10

Materials and Methods

The patient-specific guides fitted well to the native tibia and the shape of the allograft matched the osteotomies according to the VSP. The excised tibia measured 16x3x3 cm. All resection margins were free of tumor. The tumor measured 11x5x5 cm. The postoperative course was uneventful. At twenty months follow-up, the patient is doing fine with a knee flexion of 110 degrees and full active extension. He walks 1500 meters on a daily basis without the use of crutches. Furthermore, he is able to ride a bicycle. The x-ray shows progression of bony consolidation of the distal and proximal osteotomies and an optimal position of the reconstruction with a vital allograft (Figure 11). A CT scan was made 20 months postoperatively and aligned with the preoperative 3D VSP to objectify the accuracy of the resection and reconstruction (Figure 12). Individual resection plane positions could not be identified in the postoperative CT-scan due to the good consolidation. The total length difference between the planned and postoperatively measured tibia was 1 mm. No rotational malalignment was observed.

Figure 11

Figure 12

Discussion

We present our local workflow for surgical resection of primary malignant bone tumours and subsequent intercalary allograft reconstruction of large segmental bone defects using a 3D VSP and fast-track patient-specific surgical guides and implants. The workflow and technical aspects were demonstrated based on a case of a patient with osteosarcoma of the tibia. 3D virtual surgery planning is increasingly being used in the treatment of segmental osseous defects and provides important surgical benefits. The use of CAD-CAM techniques may result in a better implant fit, more precise positioning of the screws and subsequent improved mechanical stability and reduction of the risk of failure [2-5]. Use of surgical guides leads to accurate execution of a preoperative VSP. Prediction of long-term mechanical properties of the allograft is difficult. Literature shows considerable numbers of failure for mechanical reasons after intercalary allograft reconstruction in the lower extremity (16-40% nonunion at allograft-host bone interface, 19-29% fracture of allograft) [6,7]. In order to minimize the risk for allograft failure and enlarge the osteogenic potential, we combined a Vascularized Fibula Graft (VFG) with an allograft tibia, aiming to utilize the biological activity and vascularization of the VFG with the initial mechanical strength of the allograft [8]. Because of the uncertainty regarding the (de)generation of the allograft, we decided to go for a rather stiff and bulky custom-made plate design combined with locking screws.

Conclusion

In conclusion, 3D printed, patient-specific surgical guides with pre-planned screw trajectories with patient-specific plate osteosynthesis can help to meticulously plan surgical resection and reconstruction, optimize mechanical stability in allograft reconstruction and improve outcome in terms of accuracy, predictability and safety in patients with large segmental bony defects. This personalized approach should be considered an alternative for amputation or endoprosthetics. Local manufacturing can reduce production time to one week.

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Investigation on Upgrading the Life of Mechanical Systems During Transport Formed on Quantum- Conveyed Life Protype and Sample Size

Introduction

The system worked by machine transmits (generated) power to retain a planned result that necessitates forces & motion and gains mechanical advantages by correctly attaining unknown mechanisms. By carrying out the refrigerating cycle, a household refrigerator allows conditioned air from evaporator to refrigerator & freezer section. In the process, foods in each freezer and refrigerator section can be kept freshly. Refrigerator is formed of compressor, condenser, capillary, and evaporator. It should be devised to properly work under the occurrences actually employed by the end-user. As there are design weakness in the construction, it cannot immediately work in its presumed life (Figure 1). When discovering them by reliability testing, a designer may work out it in the most optimized mode [1]. It holds:

• An ALT scheme,

• Load investigation,

• An ALTs with some alternations, and

• The ability to judge well if product gets to the desired BX lifetime. As an instance investigation, the mechanical systems in transit will be examined.

Figure 1

Parametric ALT in Mechanical Product

Answering for the Schrodinger’s governing formulation can be found:

Linear transport shall be described:

J = LX (2)

As an instance, solid-state diffusion, J, shall be abridged

As Equation (3) places the inverse, the life-stress (LS) type shall be explained:

In Equation (4) the

;has some properties:

1)

in the inception has just about line effect,

2)

is discovered as a midway effect, and

3)

in the complete is immeasurable. In the midway effect, an ALT is accomplished.

As the effect materializes from effort in transmitting power, Equation (4) shall be restated as:

To attain the acceleration factor (AF), declared as the relatedness between the raised-level stress and ordinary stress, it shall be defined as:

To achieve the mission cycles for aimed life – B1 life of ten years, sample size unified with Equation (6) may be defined as [2]:

Case Investigation: Upgrading the Fatigue Life of a Household Refrigerator Exposed to Random Vibrations in Transported by Rail

Refrigerators were transported from the Los Angeles located in the West Coast to consumers who resided in the East Coast of the United States. This journey of seven days was 7,200 km for a whole travel period. As stated by field statistics, after refrigerators exposed to random vibrations in the rail transportation route (US) were shipped, they did not function because the compressor rubbers were torn and the attaching tubes were broken, accompanying by designers to ask for replacing it. That is, in the US, the interval at which first unsuccessfulness happened over two days was about 2,500 km in rail transit. In Chicago, 27% of the conveyed products was unsuccessful. As the refrigerators moved the 7,200-km interval from West Coast to Boston over seven days, 67% of the products was unsuccessful. It was obvious that the failed refrigerators had design defects. To correctly function the refrigerator for its presumed life in transit, after identifying them by laboratory tests such as parametric ALT, the manufacturer had to modify the problems (Figure 2).

Figure 2

Due to the foundation load, Y, the force transmissibility, Q, can be expressed:

where X is the unvarying solution in a physical process, F_T is the induced force, Y is the span of base excitations, r is the frequency proportion

is the damping proportion

, k is the spring quantity.

As the stress in transportation comes from the conveyed vibration loads, F_T, which may be stated as the power spectral density (PSD) level of acceleration for a determined frequency band, Equation (5) may be expressed:

Thus, found on Equation (6), the AF can be stated:

where a1 is the raised PSD level for the given frequency band, a₀ is the usual PSD level for the given frequency band, R, amplitude ratio of gravitational acceleration. After examining the calculated vibration spectra, the natural frequencies of vibration (left ↔ right and up ↔ down) were 5 Hz and 9 Hz. The damping ratio was expected to have ζ= 0.1 with a settling time of 2 sec and about 5% overshoot. The frequency proportion also was expected to have r

at the natural frequency ω_n. To achieve the AF in the horizontal/vertical orientations of random vibrations discovered from the market, raised PSD loads to the refrigerator were exerted on the shaker bench for each direction (Figure 3). The force transmissibility, Q, had the extent of about 5.3 from Equation (8). Because of acceleration of 1 G_rms, the AF was 4.0, estimated to that of worst-occasion of 0.25 G_rms. Utilizing a cumulative damage constant, λ, of 2.0, the whole AF in Equation (10) was established to have 450.0. Because the computed shape parameter in the Weibull chart was 6.41 and the lifetime target – B1 life for the entire travel interval had, the test period obtained from Equation (7) was about 40 minutes for three samples. That is, if the refrigerator was unsuccessful less than once in mission time – 40 minutes, refrigerator was acceptable for the entire travel interval of 7,200 km to survive the fatigue damaged due to random vibration.

Figure 3

Results and Conclusion

In the 1^st ALT, the failures of the stress levels — 1.00 G_rms at the natural frequency

were achieved. That is, for these conditions, rubber mounts were torn and tubes were broken at 20 min in the refrigerator samples. It occurred because there was no support in the region of stress raiser for the rubber mount to withstand the repeated random loads due to horizontal vibrations (left ↔ right). As alterations, the refrigerator was redevised as the modified compressor rubber mount, C1(Figure 4). In 2^nd ALT, the refrigerator did not fail until 60 minutes. As refrigerator arrived at an acceleration of 1.00 Grms on the bench, the natural frequency – 5 Hz – in the horizonal orientation was changed to 8 Hz by the increased damping (Figure 5). To expand the fatigue life of system such as refrigerator in transportation, parametric ALT was evolved. The quantum-transported life-stress formulation and sample size were proposed. As an instance examination, improving the fatigue life of a refrigerator failed by random vibrations in rail transit was studied. After the compressor mounts was redesigned, there were no problems for mission period – 40 min. Therefore, the household refrigerator was reassured to outlive the fatigue created and accomplish the product life – B1 life for the complete travel interval.

Figure 4

Figure 5

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New Perfection of Original Discovery of XX-XY (Female- Male) Gender Theory and Beyond: Child Development from Zero to Hero

Introduction

After new perfection of the original discovery of xx-xy (female-male) gender theory, many developments in human biology were brought in. In the referred domain previous developments reached prismatism in creating balanced gender in families. After reaching at this juncture, of prismatism for developing balanced family, it became obvious pondering that what can be further possibility of bringing new development in human biology. At birth a child’s mind organs get developed, but it has no thinking power, hence it can be considered as a situation of zero. How it grows and develops it can be made into a hero. One effort is made through aps, video, and presentations to tech pregnant women how to manifest better baby, Garbh Sanskar is taking form of a wing. [1], baby by choice and not by chance. The article presented details on Hindu Sanskar by spirituality citing case of and Abhimanu through software aps named Krishna coming through garbh sanskar, women can desgn their desire in the womb itself. The mythological story of Arjun- –Abhimnu, and devotee Prahlad who listened lord Vishnus chntings when he was in his mother’s womb. The study cites cases of success stories and the entered in big business. The 3esson is devided int quarter. The app named Krishna Coming designer baby having Sanskar and intelligence has become a business module, getting popularized through workshops and seminars citing success stories and method of building desired baby by choice and not by chance. The program is divided in sections viz beej shuddhikaran, preconception, punernavan in first three months, then chanting sanskars and for intelligence through slokas, music and storytelling and depiction of preference of the baby character. In the second third month duration spiritual sansakar recited. The last quarter is devoted to yoga and exercise. Doctors find such mental practices and situations have good family bond resulting comfort and coherence in family. This app has become a new wing forming basis of yoga and vedic mantras. This sanskar baby involves family support where many events-based family functions are performed. The app has also program for children up to age of 12 years., while business-oriented medication, yist lesson, yoga, meditation etc, but there is no insight of bio magnifications and what happens to the good and bad effect of shocks, which happen by any unknown reasons. Thus, the interest being brought up in the present study is well alive need full-fledged study on genetic theory, which will advance human biology, in general.

Objective of the present study was to find how further growth can make one from zero to hero. This study made process based situational study and arrived at meaningful conclusions in development of child from zero to hero. The study cites cases which had taken huge stakes in various religions since long past. It comes from that any initial shock on child at initial stage when one is mentally zero, will- have lot of implications on its future development of personality. Study identified initial shock defers child’s mind diversion depending on available visionary exposition and adverse impact of surrounding environment. The well-known historically famous cases are cited as examples in support of further upcoming results and bio-factors responsible for such developments are identified and substantiated. Study sets extensive role of mothers beyond mere nine months; period child is reared in womb. This study provides a new dimension in sociological provocations in International Mother’s Day. The study sets new steps and routes for celebrating International Mothers’ Day using new perfection of original discovery bof gender theory and beyond. The study first considers advances in prismatic gender, it takes all possible cares during the pregnancy, deliveries, care postnatal, and child care making one as an adult hero, something a different personality from one gets developed under usual life course processes. The study sets innovative wisdom for developing a genetic personality from zero to hero, which becomes the first scientific visionary bio study.

Materials and Method

Existing Scenario on Child and Mother Care

Child is created by mother, which involves process. Mothers showed tremendous concern on welfare of children as display of motherhood as evident from media reports on International Mothers’ Day on May 15, 2023 [2]. This study brings developing focus and its appropriateness and efficacy. Worldwide mothers initiated campaigns on combating global warming and environmental pollution becoming injurious to health, adopt strategic urgent mitigating policies.It is giving feeling that real role of mothers in caring children has left right path, hence many worldly affairs cope in. There is need to bring childcare inducing genetic reason, extending role of mothers and making its international understanding value highly precious and effective.

Ancient Scenario on Mother and Childcare

There were plenty of miracles in childcares in the past. Efforts were made to bring well known cases so that readership gets quick comprehension and visualization of cited case studies. Historically famous and well-known cases were cited as examples in support of further upcoming results.

Siddharth to Gautam Buddha: Siddhartha was born in 563 BC princely family in Lumbini in Nepal. He grew up in great personality and became Mahatma Gautam Buddha. His life course bccame a path setter for the new generation [3]. A new bio factor was identified and will be taken up in the subsequent path of the study.

Savitri Bai Phule Mahatma Jyotibarao Phule: Jyotiba Phule was a great thinker, social reformer, philosopher, editor, and revolutionary. Savitri Bai Phule, on the other hand, was illiterate before marriage, but Jyotiba Rao Phule taught her how to read and write. Later [4], Savitri Bai Phule became the first female teacher in the country, not just for the backward classes but for the entire nation. At that time, the condition of girls was very pitiful, and they were not even allowed to study or write. This personality brought a new era of bringing education in girl children, who became mothers a piller in the development of the genetic theory. This bio factor becomes a catalyst [5] in childcare from zero to hero.

Albert Einstein-An Exemplary Genius Personality: Born on March 14, 1879, in ULM, Germany as first healthy child to Pauline and her husband Harmaan, creating a very delighted parents [6-8]. The father Hermaan was an electrical engineer at the time when electrical products were new and exciting area to work in. Next year the Harmaan family moved to Munic to team up with his brother Jacob to start makeup of electrical equipments. The child grew with his parent’s given name Albert and became great scientist Albert Einstein.

A Girl with IQ More than Genius Einstine: Daily News Paper [9] presented a newspaper of a girl having intelligence quotients (I.Q.) more than that of Albert Einstein. The details of such I. Q. will support identification and evidence in the coming study.

Advancement in the Domain of Development of Women and Child

This researcher brought new perfections in original discovery of xx-xy (gender theory) in 1905 [10], ie after one and a quarter century later, overcoming plenty aberrations and becoming scientific basis back people lose trust on such scientific advancement, and adopt back on believes based on different prevailing religions prayers. How this new perfection brings scientific advancement in human biology to come in resulted in bringing prismatism in human biology [9].

New Bio-Factor in Childcare Shaping Future Personality

Deep case by case study showed a bio-factor which has strong influence on development of individual personality. This bio-factor is the level of pH of urine. This has several ranges which implicate mental growth making intelligent as well as a bad personality by process of biomagnification in the life course and making nature of individual personality. This aspect will be presented in the result part of study.

Acquisition of Data for Further Study

Well known cases of aberrations in gender balances leading to misbalanced families having social and economic variations are families and associated genetic disability, as well as ailments are brought in the study [11].

Results

There are plenty of aberrations in gender theory results. Well known cases of such aberrations are classified, and such groups are present in the following subsection.

Selected Case Study Having Misbalance in Family with Girl Children and No Male Child

resents well acquainted case known to the author. The case-by-case deep analysis was reviewed, and crucial factors identified. The misbalance in family occurs due to low pH (ie high acidity) of urine. This chemical dis balance occurs due to many female genders related problem of urinary tract. The period irregularity turns to bring diffect in system add to the problems. Therefore, mothers are required to take pre-pregnancy medical advice from an expert doctor, which is usually done after conception of child. Such pre pregnency medical advisory is reposted by this author other study [10] In this domain lack of scientific knowledge as well as failure of the expected results from the original theory reverted people seek God’s blessings. The helplessness situation people accept in whichever type of gender takes birth. The new perfection [5] has reached to prismatism of childbirth and make family become gende balanced. Education of girl children which become mothers in due course will be able to understand the process. Even in the most developed countries of world only 30 percent of parents plan pregnancy where nearly 24% deliver babies. The remaining 70- 76 % child borns in their natural process of evolution. Therefore, this situation is not likely to be overcome in a short span of time. Pregnant mothers visit doctors for normal growth, which remains tagged to food and nutrition of mother and child. Nevertheless, the new perfection overcomes such limitations. Pre consultation over comes likely complexity of growth and delivery. Educated lots prefer to go for caesarean delivery, where both mother and child get needed care. The medical care facilities usually remain lacking and many mortalities of mother and child cannot be over ruled. Family life gets sad sailing and life course development with complications. Study could not make any study on visible ailments of mother and the girl children as result on inherent limitation and people avoid talking such ailments, as natural situation.

Aberrations in the XX-XY (Female-Male) Theory, Social and Family Health Having Only Male Children

Table 1 presents case study of well-acquainted family having only male children [2]. Cases reveal the special health situation of parents. The couple with one male child invariably father suffered baldness and occasional headache. In case of couples having two male children there occur plenty ailments in fathers as well mental disorder in mothers. Large no of cases in this category showed a variety of ailments in fathers asewll as in mothers. Severity of headache and mental disorder were found to increase in couples with three sons. In contrast, the couple with four sons both parents suffered baldness and mental disorders. The social implications are different from those that existed during the 19th century when Jyotiba-Savitribai Phule were involved in overcoming problem then [3]. By that time there existed no scientific gender theory. This study will take account of new scientific advancement of gender xx-xy female-male theory [10,11]. As it was apparent, in births of females (Table 2), there also occurred aberrations in birth of male children (Table 1). Such implications will be taken up in clarification in the following part of manuscript.

Table 1: Misbalance in family having only male children.

Note: * *Subscripts M and F are arbitrary. They merely signify different identification in array.

Table 2: Aberrations in xx-xy- (female-male) gender theory and resulting gender misbalanced families.

Note: *Subscripts to M and F are arbitrary. They merely signify different identification in array.

Ancient Wisdoms

From Siddharth to Buddha: Coming to the bio-factor the life course study of long journey from prince Siddhartha to Gautam Buddha [3] was deeply studied to ascertain the bio-factor for taking lesson in bringing any prismatism in child development cares. The prince Siddharth s mother died nine days of his birth, whien child has zero wisdom. This became a biological shock implicating the future life course of a prince, what to talk for gentry in general. As the prince grew from zero wisdom, with development of wisdom with growth of mind became curious to find many answers to know Table 3 presents the questions then and resulting answer scenario now.

Table 3: Self posed questions of worried Siddharth and their answer now.

Savitri Bai Phule a Legendary Social Reformer: To break this tradition, Jyotiba Phule and Savitribai Phule established the first girls’ school, named Balika Vidyalaya, in Pune on January 1, 1848, which was the first school for girls. Six girls were the first to enroll. In this way, they opened 18 schools for women, and Savitribai Phule also started widow remarriage and established an ashram for widows. Seeing the tendency of infanticide, Savitribai Phule established the first child protection home in 1888. Along with her husband, she prevented a Brahmin pregnant woman named Kashi Bai from committing suicide, and also adopted her illegitimate child Yashwant as her own son and educated him. Later, Yashwant became a famous doctor. Savitri bai Phule had made the prevention of untouchability an important part of h     er work. All campaigns of Savitribai Phule and overcoming atrocities, then led to development of prismatism in in human biology for bringing gender balanced families [5]. Subsequent scientific development of xx-xy (female-male) gender theory got discovered by Wilson and Stevens in 1905 [11]. But expected results got aberrated making people to lose trust, which was taken as pondering situation [12] Such results were brought in Tables 1 & 2.

Albert Einstein: Albert Einstein, the brilliant scientist, who is now every one’s idea of an absolute genius, who had concluded that acceleration (speeding up) of an object such as machine bends time and space through which it travels, which provided new scientific basis of ecological changes at different locations in spatial and temporal position in globe. Elbert Einstein also said that people think that I am genius, but the fact is that I live with problem for longer time. This fact is taken up to explore and create reformation of educational systems that creates mandatory provision to remain in contact of syllabus and revision to produce genius generations [7,8]. The results of the study substantiated improvement of efficiency of educational systems, without further incurring extra burden on country’s economy, development of genius gentry to bring several social capital and intellectual properties in different areas Emergence of many supporting developments in the journey from Siddharth to Gautham [4] need deep analysis. This part of the study will be taken up in the subsequent part of the present study under a separate section covering all three previously brought out bio-factors.

Analysis for New Bio-Factor

Previous sections have covered resulting situations of misbalance in genders of family, succeeding studies showed there are many genetic disorders which display genetic features in parents. This implies that the developing offsprings will have their next generations with varying magnification of bio-factors. Such-bio factors enhancements and depressions will bring different natures of personalities. To proceed further wisely selected cases of well-known personalities in different aspects were brought here to enable readers understand and comprehend situations of ready references. The bio-factors are brought here in the following section case by case descriptions, which were brought in section 5.3.

Hypothesis of New Bio Factor: Previous dealings and results enabled formulation of a new hypothesis of bio-factors which develop and bring nature of personalities. At birth when child is born under normal situations, all body organs including the brain get formed, but its thinking power is governed by mother care immediately after birth. Any setback during that tender growing stage hinders normal growth. It also understood that any insufficiency in food and nutrition turns the growing child to follow growth with some kind of genetic diffect, resulting in genetic disability. Coming to a situation after the birth normal or with any kind of genetic disability, any kind of shock suppresses normal bio-factor growth. As wisdom grows, the growth gets deformed. At this juncture there become two routes of personality development viz forming bad vis a vis forming good personality. The deferred growth takes its form with added strength. At this time the further features grow as per scenario exposure coming to the groing child initially having zero strength of mind. This hypothesis is further substantiated by the exemplary cases citations and justifications. It also enabled fixing good features to developing personality becoming hero.

Bio-Factor in Developing Personality: From Siddharth to Gautam: As mind grew Siddhartha started thinking and self-posing questions and remained thinking about it with developing mind. He was not allowed to go out of palace, in mean time he was getting normal with that situation he ws allwed to go out for getting familiar with situations Siddhartha was a princely child. His mother was reported died after 9 days of birth when mind had almost zeo thinking power. There was a lack of intimate mother care. During that time Astrologers (Jotishi) predicted that Siddharth would be either a king or he will be a bhiksu (saint). He was retained in palace where he grew with searching answers to his self poed questions brought out in Table 3. Siddharth was allowed to move out where he perceived validating exposures intensifying his worry. In mean time he was married and a son was born named Rahul. Inspite of all luxurires and sufficiency of means of pleasant livng of life he left house and beame a bhikshu. With further growth he became a wisdom acquiring personality under the Bodh Gaya Tree, again in isolation medication. He started moving and preaching such answer, which became religion Buddhism, spreading in countries in east of Indi namely, Thiland, Indonesia, Koreass, China and Japan.

The foregoind details confirm the hypothesis of impact of shock, magnification of bio-factor and impact of subsequent exposures as mind grows after any kind of shock. This fact is further substantiated by exemplary research result from Safdarjung Hosptal in New Delhi [13], May 31 saved2023]. Children kept well by keeping mother in ICU providing Kangaroo mother care to childbirth before time and underweight could be saved from septisemia, a blood poisonous infection disease. This study on 3200 children showed that 37% of children could be saved from infection of sepsis. Children were given 16 h skin touching under Kangaroo mother care and given feeding proved healthy children.

Social Reformer- Savitri Bai Phule: Savitri Bai Phule was born in 1831, when there occurred lot of atrocities to women and girl children. had occurred when customs prevailed causing atrocities towards female children, there used to be lot death due to occurrence of different types of epidemics with lack of adequate medical care facilities. While males could get remarried, but female genders were debarred taking any part in family auspicious functions. Their heads were shaved and were debarred in mant activites. This and many other facts compelled then child infanticides, all adverse situations changed Jyotiba Phule and Savitri Bai Phule minds for bringing social reformations. Excessive exposures of atrocities became reverting such social repulsive biofactor. This author brough a prismatic gender balancing new innovation [3].

Absolute Genius Albert Einstein: Albert Einstei was born in 1879 and had all luxurious life in Germany. The early life depicting iterature presented decorated situation of early life days. Hence, it is difficult to find the identified factor of intial shock which is responsible for bringing later transformation of bio-factor viz initial shock. An available document established that Albert Einstein had excellent initial exposure conforming and doing and validating is hypothesis in log time remaining with problems. The existing backing and developing scenario and getting work opportunity in emerging branch of electronics, enabled him to remain in that field for long time. In his flourishing long life course he developed with confidence special theory in 2009 and general theory of relativity in 1t 36 year age. These figures and facts prove the extensive exposure at the time of growing wisdom brin lot enhancement in genius capability. Recently [9] a daily newspaper report quoted a case of a girl having intelligence quotient (IQ)more than Albert Einstein, passing master’s degree in system management at the age of 11 years. It was reported that the girl had lost her memory power during her early part of childhood. This report supplements the part of hypothesis on shock or any set back getting enhanced when wisdom grows at later time of mind development. Thus, the entire aspect of hypotheis get fully established and substantiated.

Bio-Factor Leading to Development of Extremely Bad Heroism Personality: Previous elaborations and cited examples covered God personality. This section is bringing supplementation and substantiating cases which produce bad heroism personality. Such cases are plenty thes days. Ase largely remains in prison and judicial custody. These are largely murders, thiefts and extremely unpleasant anti-social undesirable activities. All such cases have some shocks at intial time when their minds had no thinking power, had mental depression as well as exposure of such bad surroundings and bad company. It would be unfair to cite such names. Readers will be sufficiently convinced to comprehend reports and cases appearing in day to audio vidual and daily newsprint media. In New Delhi one lady murdered her colleagues on saying derogative word to her deceased father [14]. The lady having diverse from her husband and excessively drunk killed other women 32 year by poking knife. This type of brutal mind develops under some frustration leading to mental instability. This aspect of the hypothesis brought earlier is also fully established and substantiated. Recent report coming in daily newspaper that in America 1,22,000 people were killed by indiscrimate shooting by gun between January 2016 to Decmber 2020 [5]. Law and order situations have become a subject of difference between opinions, justifying keeping gun is individual right for self-defense. As brought out earlier, this situation is developing due to mental disorder creating bad personality, which becomes befitting topic brought under this study denting genetic solution to become ideal and permanent solution [15].

Newly Composed Module of Childcare Developing from Zero to Hero

Based on the foregoing details a new innovative childcare module was formulated for developing exemplary zero to hero personality. The genetic prismatism over comes genetic disorder enabling gender balanced families, sufficiency of mother care to meet oxygen and nutrition enhanced demand, peaceful comfortable environment, overcoming stressful situation by conducting scesarian delivery, that keeps continuing mother care touch with exposure of good and advancing scenario enable developing exemplary genius gentry. Any disorder defers such growths, but it is enhancing extra ability power of other organs making a remarkably bright heroism. Thus, this study covers a broad spectrum of child care bringing from zero to hero by genetic development. Kangaroo, continuing mother care from zero to childhood and leading to adulthood, bring exemplary personality, extending role of mother care more important that what has been thought over earlier. Contrary to this situation any initial shock tuning in mental depression with later enhanced bio-factor makes criminal background personality. Such bad scenarios have been developing world over, coming to notice, these days. Any shock defers growth and bad exposure creates excessively strengthened criminal attitude personalities bringing unpleasant antisocial activities creating plenty law and order problems for the country’s world over.

Nurthure of Exemplary Hero and Overcoming Bad Criminal Antisocial Activity Performers

The previous section covered different aspects of cares for building personalities from zero hero. It is well known to set such ideal personality, some kind of esteem recognition is awarded to make an exemplary case. In the case of Albert Einstein, the award was a noble prize. In the other situation when there occurs some mental disorder there is custom of creating and giving mental vitamin. These days life course is full of challenges, which leads to mental misbalance, is thought over by sociologists [2023e]. Such sociological wisdom has reached the level to have gossip and some mend freshening talks as mental vitamins. The new perfection in gender theory and beyond deals this uncomfortable development of mental situation as mental disorder. The study reached the identification of a bio-factor which needs such mental misbalanced situation a control measure. Therefore, mere social thinking is not enough to deal with such a bad scenario. It needs scientific justification for tackling such misbalanced situations. This study accomplished both the situarions of identification of individuals with such mental misbalances and needed control by the most suitable sociological implicating punishments as well as some medication. These mental misbalances have many visible as well as behavioral indications, which become advancement in human biology.

New Curative Resolution for Overcoming the Extremities Devastated Spoiled Minds

Previous sections dealt with bio-factors, effect of any shock, deferment of growth and alter overcompensating build of mental growth making genius, diversion of minds and acquiring some specific skill. This fact was exemplified by tremendous enhancements of memory power of Soor Das Ji, who wrote Shrikrishn gatha. This section is devoted to how magnification grows in creating bad personality due to misbalance of mind. This situation is indicated by range of pH, viz urine pH. This ranges from 5- 12 safely can be considered 5 to 10. This pH will go on developing bad personality and the hero will behave differently in developing situations. This can be easily fixed by conducting tests of cases of pH of different types of crimes for which one is put in prison. The pH test range can be developed to make relation trend between pH and the type of bad personality. This information can become a guiding factor of keeping different categories of criminals of cr505na3s personalities in different categories. Such scenarios can be overcome by mnoeuveration of pH by food and nutrition, especially when the mgnifiction is in low range. There have been tremendous cases which take the form of men, meaning thereby what one sets doing on. For example in many murder cases criminal is seen continuously repeating his cr50e, in extending order Such situation is found even in fmous Tihar jail in Delhi, where one prisoner goes on killing the other prisoner.

This situation takes the form of severe crrime. The many extreme minded bad personlty people need punishment which should keep them reminding the bad activity done by him. In many countries death penality is banned and life imprisonment is granted in one course of justice or the other. Further, life imprisonment is for only 14 years or so and the law-and-order situation being a state subject, criminals get bail and finally get free from such heinous crimes. The social punishment will serve two aspects; first make bad personality not to do any bad revengeful action ofter he is out of jail from one or other pretext. The second aspect is that he will get socially humiliated and on lookers will also take lesson remembering that one should be obstinate from doing such bad behavior for which he had been given the type of social punishment. The social punishment can be of type of making hole in ear plugs and shrediing of ear or something of that like punishment. This bio-factor will be guiding factor in overcoming of in discriminate shooting in U.S.A, for which there exists no pragmatic control measure [5]. Such an identified person may not be given licence f6r owning the guns.

Discussion

Developing Interest in Human Biology

There had been widespread interest in developing children having good health ie free of any genetic disorder, which takes long time in overcoming such ailments and intelligence. Now there have been interest even in womb under the banner of Garbh Sanskaar, which has taken shape of business module in human biology, which takes stake of mythology of Arjun and Abhimanu [1]. This study derived on the basis of biological factors covering broad spectrum of human biology ranging since BC to AD including present time. Therefore, the research presented in the present study is on a scientific basis, which becomes a biological advancement.

The New Prismtism in Humn Biology

There has been development of bringing prismatism in human biology enabling gender balanced family and overcoming lot of adversities on women and child [5]. Usually, people had been feeling such developments in gender or birth of child mere grace of God, for which people follow different paths induced by different ideologies and situation of minds. This scientific biological advancement is devoid of any cast and religion.

Developing Divisions and Wings in Development of Children

This study has displayed different stages viz preparatory gynecologist advise, which is corresponding to Beej Shuddhi in garbh Sanskar, Conception and taking care of food and nutrition in lieu of various many auspicious celebrations during first timahi, second timahi and third timahi covering nine month durations in mother’s womb, which is main activity of growing gynecology departments in Government hospitals. Next stage is children care before adolescence and last developing adult. The biological factor guides how to rear a child from zero to hero, which is entirely a new insight in human biology. This entire domain covering a broad spectrum comes with how any shock leads to the development of both good physical, mental health and intelligence. Any unavoidable shock depressing normal growth during the process defers growth and that becomes a stint or extra intelligence, ability as well as development of bad personalities. This study opens new frontiers of child development from zero to hero in the domain of good personality. It becomes beyond control when such shock turns in to the development of a bad personality. The personality man oeuvre of good and bad personality becomes a subject in the following section of the study.

New Perfections in Personality

In the domain of scientific theory of gender development discovery came about one and quarter century ago [3,11]. But they’re occurred plenty aberrations, which became a pondering situation. Deep studies of well-known cases arrived coming up with new perfections and beyond [12]. This study is going beyond in this domain with objective of developing children from zero to hero, which is new aspect and bringing advancements in biological aspects.

New Promotion and Overcoming Good and Bad Personalities

The previous section covered the possibility of building from zero to hero good personalities as well due to shocks and bad depression and exposures to bad situation, development of bad personalities doing anti-social activities. Thus, it becomes imperative to review what to do to foster good personality as well as discourage or transform bad personality to good personality to moderate attitude of the undesirable antisocial activities. The senior citizen well acquainted with historical things in locality and elsewhere can play a good role of narrating to youger generation in form of telling legendary success stories and examples. One example of a highly intelligent personality is in the form of awards. The Noble prize is the highest esteem prize award for extra exemplary intelligence. Likewise for manoeuveration of such bad antisocial activities judiciary and imprisonment are universal provision of punishments. Although so long as the media keeps focussing continuously people become aware and think of restraining such bad activities. Largely, bad personalities complete the imparted punishment or come out of prison after obtaining bail, hardly become good personality, rather they start doing same previous antisocial activities again and again. Therefore, the stint of bio-magnified personalities needs some social punishment so that it becomes a live moving example of bad personality. People in general will point out and make bad humiliating situations for the bad personality. As death penalty is largely banned, social punishment in form of punching or making hole in ear or slashing may become mode of such social punishment. This is a new vision of suppressing the bad attitude of bad personalities, which will get refined by people’s reactions in due course of time.

Economic Gain and Feasibility

The study on development of childcare for making from zero to hero is highly feasible as generation goes on moving from one to another without any definite cutoff line. Hence it will be highly feasible transformation in the community and society as well as for any country. God personalities will make innovative intellectual properties which will make gain for the countries. Similarly, suppression of bad personalities will help save resources and develop bad to good personality. The crucial bio-factor needs case studies, which is beyond scope and feasibility of the present study.

Conclusion

The study fixed bio-factor drawn from long time human biology by deep studies of life courses with respect to health and intelligence. It came to realization that any set back during early stage of zero to hero development defers growth for some years and gets further revamped by the factor of biomagnifications. Mother cares much beyond ie mere understood for nine meonths in womb, is needed for developing good personality, builds strong bond for International Mother Day celebrations. Such growth process creates extra intelligence for good hero vis a vis bad personality creating antisocial activities, which become problem of widespread nature. Study comes up with further fostering of good personalities as well as discouraging the bad personalities. The identified bio-factor has been established and substantiated in the study, which opens new frontiers in human biology for developing childcare from zero to hero.

For More Articles: Biomedical Journal Impact Factor: https://biomedres.us

Psychological Intervention in Prostate Cancer: A Review of the Literature

Introduction

The central theme of this literature review focuses on the need and relevance of implementing a psychological intervention plan for men with PCA. Firstly, the general characterization of the disease will be made and presented in statistical terms at a global level. Secondly, several studies implementing psychological intervention programs for this target audience will be discussed, highlighting their challenges and results. Next, the crucial points to be included in a plan will be reviewed, namely the impact of diagnosis, lifestyle, and palliative care, to contribute to reducing the mortality rate of cancer patients, increasing their level of quality of life and, at the same time, positively influence the environment.

Method

The literature review was carried out through an electronic search for articles available in the b-on, Google Scholar and PubMed databases, where it was possible to collect 54 articles. Descriptors were used such as: “prostate cancer,”; “health psychology,”; “well-being and prostate cancer,”; “erectile dysfunction and mental health,” and “psychological intervention plans.” The research was composed of scientific articles, chosen after an initial review of abstracts, titles and results, considering the following inclusion criteria:

1. Year of publication: articles published between 2003 and 2023.

2. Language of publication: articles written in Portuguese and English.

3. Theme: articles that included the keywords: “prostate cancer,” “mental health,” “well-being,” “quality of life,” “mental health” “health psychology,” “erectile dysfunction,” “intervention plan,” “psychological intervention,” “prostate cancer and palliative care” and “environmental sustainability”.

4. Access: free.

In this sense. The exclusion criteria were:

1. Articles prior to 2003.

2. Published in a language other than those mentioned.

3. Did not directly focus on the topic of the review or did not address its target population.

4. Had limited or paid access.

There are also additional references that were not considered in the research, as they include statistical data referring to the National Statistics Institute (INE), the World Health Organization (WHO), the National Oncological Registry (RON), the Regional Directorate of Statistics of Madeira (DREM), Institute of Health Administration (IASaúde), or even entities, associations or reference organizations such as the Portuguese League Against Cancer (LPCC) and Order of Portuguese Psychologists (OPP) and the World Health Organization (WHO). The research took place between September and October 2023.

Prostate Cancer: An Approach

Definition

According to the (WHO, [1]), cancer is the generic term used for a vast group of diseases that can affect any part of the human body. It is characterized by the rapid growth of abnormal cells that can invade our body and spread throughout the organs. This type of chronic disease is the most significant cause of death worldwide, reaching approximately 10 million deaths in 2020, with 1 million and 41 of the cases corresponding to prostate cancer, the central theme of this review. This type of malignant tumor manifests itself in the prostate, a gland of the male reproductive system located below the bladder and front of the rectum. It occurs when there is mutation and uncontrolled proliferation of cells in the gland, which, when causing metastases, can affect other parts of the body, such as bones and ganglia (Silva, [2]). It can cause urinary tract problems (e.g., incontinence) and erectile dysfunction. Its detection can be carried out through rectal examination and clinical analyses for the Prostate Specific Antigen (PSA); however, as they are not considered sufficient for diagnosis, other tests, namely trans-rectal, cystoscopy, and biopsy, will be necessary. PCa treatment may involve surgery (e.g., prostatectomy), hormone therapy, radiotherapy, and chemotherapy, or upon medical recommendation, just observation and monitoring (O Cancro, n.d. [3]).

Statistical Data: It is the second most common form of cancer in men worldwide, with a higher incidence in men from North America and Europe (Globocan, 2020). In Portugal, it is the most relevant malignant tumor in this sex, with 5741 cases representing more than a fifth of the total tumors that occur in a year in men. According to a study carried out by INE, the analysis of the incidence of malignant tumors in Portugal in 2017 refers to prostate cancer as one of those with the highest incidence (65 cases per 100,000 male inhabitants), with an average annual growth of 1.3% from 2012 to 2017. The 50,151 new cases of cancer diagnosed in Portugal in 2018 corresponded to an increase of 3,427 new cases compared to 2010 (INE, 2018). However, it is rare for a man under the age of 40 to be diagnosed with this disease, with its incidence increasing from the age of 50, indicating that two in every three patients are over 65 years old at the time of diagnosis (RON, [4]). In the Autonomous Region of Madeira (RAM), 130 new cases are registered annually (IASaúde, 2018). Regarding the number of deaths, according to DREM (2020), 38 deaths were recorded due to this malignant neoplasm in men aged between 55 and 94 years, with a higher incidence in the age group from 80 to 89 years, recording a total of 19 deaths, between 65 and 69 years old there was only one single death. In terms of marital status, it is known that more than half of the men were married.

Target Population: From a generational point of view, Baby Boomers, born between 1946 and 1964, and Pre-Boomers are the most likely to develop CaP. The first generation considers quality of life an important factor and is more likely to seek health services than previous generations. These differences are due to their higher level of educational qualifications and the fact that their income is higher than that of Pre-Boomers (Scales, et al. [5]).

Masculinity: In Western culture, there is a tendency to hide signs of susceptibility or personal failure, encouraging the idea that seeking help is still synonymous with vulnerability (Soares, [6]), especially in men, the masculine image is associated with strength, invulnerability, and authority, promoting an attitude of independence reflected in their (non) interaction and demand for health services (Galdas, [7]). With psychological support services in the oncological field, there is a tendency to refrain from resorting to this type of intervention (Forsythe, et al. [8]). However, according to scientific evidence, men who display masculine characteristics, such as independence, are likelier to report less positive emotions (Bums & Mahalik, [9]).

Risk Factors: Several non-modifiable risk factors are identified: age, ethnicity and family history (Gandaglia, et al. [10]). Older men are the most likely to be diagnosed, with the risk increasing significantly after age 50 in Caucasians without a family history of the disease and after age 40 in black men with a family history (Harrison, et al. [11]). The latter are those most likely to develop it, followed by Caucasians, Latinos, Asians and, lastly, indigenous people (Taitt, [12]). Finally, having a first-degree family history of having developed PCa is also a risk factor for the diagnosis (Hemminki, [13]). Regarding modifiable risk factors, the following stand out obesity, smoking, and alcohol consumption (Gandaglia, et al. [10]). Obesity, associated with altered metabolic levels (McBride, [14]) and essentially related to unhealthy lifestyle habits, is responsible for the development of certain chronic diseases, high blood pressure, diabetes and even PCa (Harrison, et al. [11]). Studies reveal that if the body mass index (BMI) is high, individuals have a greater risk of developing the disease, with faster and more aggressive growth (Uehara, et al. [15]). Regarding tobacco consumption, there are few studies developed that consider it as a direct risk factor. However, the scenario changes when combined with overweight and obesity (Jochems, et al. [16]). Regarding alcohol consumption, according to a Finnish study in which more than 11 thousand male twins participated, it was clear that high and regular alcohol consumption is associated with an increased risk of the disease when compared to light consumption (Dickerman, et al. [17]). It is therefore concluded that consuming alcohol in high quantities is a risk factor for prostate cancer (Perdana, [18]).

The Need for a Psychological Intervention

The incidence of prostate cancer is growing exponentially, and there is a tendency for more and more men to receive the diagnosis as well (Skwirczyńska, et al. [19]). The emotional and psychological impact of a prostate cancer diagnosis leads to the unknown, doubt and uncertainty in the lives of those who receive it. There is an emergence of questions for this new phase in which patients begin an adaptation process that can give rise to psychological disorders (e.g., depression and anxiety) regardless of the phase they are in: diagnosis, treatment, recovery, or palliative care (Sousa, et al. [20]). The biopsychosocial factors associated with depression and anxiety in a patient with prostate cancer involve three variables: biological (e.g., erectile dysfunction and urinary incontinence), psychological (e.g., personality characteristics), and social (e.g., socioeconomic status and family/ social support) (Fervaha, et al. [21]). Scientific evidence suggests that a harmonious environment should be cultivated in hospital units to give patients space and a place to express their vulnerabilities, promote psychological self-care strategies, and practice psychological intervention programs focused on improving their quality of life (Pan, et al. [22]). In a postmodern context, where reality and the universe can take on multiple meanings, it is crucial to establish connections between different scientific disciplines, promoting the development of science that studies human behavior and the mind (Soares, [6]). In this sense, psychological support is a highly relevant complement to cancer treatment (Skwirczyńska, et al. [19]). CBT, a psychological approach without the use of medication, has demonstrated considerable improvements in the quality of life of cancer patients, relieving symptoms such as anxiety, depression, fatigue and sexual problems, promoting patients’ confidence during treatment, as well as changing distortions of irrational thinking to a more realistic and optimistic perspective (Yuan, et al. [23]).

What Has Been Developed and Applied

A psychological intervention program to prevent or improve the adverse effects caused by PCa treatment, with multidisciplinary content (nutritional, physical, and psychological), used psychotherapy as a method, offering psychological counseling and emotional support in individual and group sessions. The results were viable and beneficial, revealing that psychological intervention is a way to improve the well-being of patients immediately after therapy significantly. (Vartolomei, et al. [24]) According to the literature, online interventions are a way to offer quickly and continuously accessible, informative content at all stages of the disease (Bartels, et al. [25]). It demonstrates its effectiveness, for example, in treating the sexual well-being of both men and their partners, providing adequate support, enhancing the best results, and contributing to an increase in quality of life (O’Connor, et al. [26]). Another study developed with patients with PCa presented an online intervention program that addressed topics such as daily life, diet, physical exercise, and relaxation techniques using Person-Centered Therapy as a method based on the experiences and psychosocial context of the public-intervening target. The results demonstrated that planning and development are fundamental for a successful behavioral and psychoeducational intervention (Hughes, et al. [27]).

A pilot study in which patients with advanced PCa participated focused on a multidisciplinary approach to ensure long-term behavioral changes and adopted various strategies to improve physical resistance and mental flexibility, promoting dialogue and reflection on each participant’s health experience in all sessions. The study revealed that participants highly accepted the program (Thederan, et al. [28]). In general, interventions that addressed the Cognitive-Behavioral Theory in patients with PCa revealed several advantages in terms of mental and sexual well-being. Developed in person or digitally, they are a vital source of support for dealing with issues that require a more extended look, in addition to improving symptoms of depression and contributing to greater sexual satisfaction (Pieramico et al., 2023). In this sense, this literature review aims to reinforce the need for the relevance of investing in psychological intervention plans for men with prostate cancer to reduce the mortality rate, increase each person’s quality of life, and contribute positively to environmental sustainability.

The Impact of Diagnosis

Receiving a cancer diagnosis triggers several emotions and different reactions that arise, along with stigmas and prejudices. According to a study developed by (Porto, [29]) participants reported experiencing feelings of anguish and anxiety, associating the diagnosis with death and suffering that was alleviated with family, hospital, and religious support. The data reveal the need to make this moment of vulnerability more welcoming through the development and investment of spaces dedicated to cancer patients and their families or relevant people, such as reflection groups, in which issues such as changes in male identity, for example, can be addressed and discussed. Another example to explore is employment issues, as the treatment chosen impacts the work capacity of men with PCa, changing their career or retirement goals (Ko, et al. [30]). The patient’s expectations regarding treatment results, both in terms of efficacy and adverse effects, appear to have more impact on treatment-related regret than factors such as the severity of the disease or the type of treatment itself and its side effects., such as urinary incontinence or erectile dysfunction. However, the diagnosis is considered a source of concern for men, who state that the adverse effects of the disease have an impact on their masculinity and self-esteem, as there is a feeling of loss of control over their lives (Cockle-Hearne, 2016). Furthermore, studies show that suicide rates increase during the period immediately after diagnosis (Fox, etal. [31]) For this reason, psychological support is central to the patient’s decision-making, guiding them toward a better choice. Studies reveal that the more informed the patient is about the treatment and its adverse effects, the better they evaluate their quality of life due to their expectations (Orom, et al. [32]). In this sense, the role of health professionals assumes excellent importance, guiding the patient at the time of diagnosis and before treatment, considering their values and priorities to contribute to conscious decision-making and reduce their suffering and regret. (Wallis, et al. [33]).

Erectile Dysfunction

According to the literature, the type of treatment chosen can negatively influence a man’s sexual function, and it is crucial to ensure that the patient discusses the possibility of this consequence in order to minimize the impact on their quality of life after surgery or another type of treatment. (Nunes, [34]). According to a study carried out with 60 men diagnosed with prostate cancer, 37% had erectile dysfunction, 26% reported some dysfunction related to ejaculation and 48% had a decrease in sexual desire (Saitz, et al. [35]). In addition to the fact that receiving a PCa diagnosis generates psychological instability in both the patient and the partner, leading to a decrease in sexual activity (hyun, [36]). It is associated with the presence of stress and depression arising from sexual dysfunction, triggering problems in the couple’s relationship. Studies reveal that the higher the levels of anxiety in men with prostate cancer, the greater the incidence of depression and sexual dysfunction (klett, [37]).

Lifestyle and Environmental Sustainability

While some strategies for dealing with the planet’s health require exorbitant investments and changes to the political system, others involve simple lifestyle changes. In this sense, choosing to exercise regularly, eating healthily, and promoting psychological well-being provide the best results and the most effective practices to implement among patients with PCa (Zuniga, et al. [38]).

Physical Activity

Habitat loss and decrease in green areas, often linked to industrial development and urbanization, have been linked to an increased occurrence of prostate cancer (Bodiwala, et al. [39]). According to a study on the relationship between green areas and the development of neoplasms, men living in these areas had a lower risk of developing the disease (Demoury, et al. [40]) and contributing positively to your health, promoting the practice of physical activity, such as walking and cycling, which also has beneficial effects on urological issues, such as urinary incontinence and erectile dysfunction (Zuniga, et al. [38]). Another type of activity that can be carried out outdoors is the practice of yoga, according to an intervention carried out with patients undergoing active radiotherapy treatment, in which they took yoga classes twice a week for a period of between 6 and 9 weeks, encouraging results were presented, indicating levels of stability in fatigue indices, for example. According to the authors, during weeks 4 and 5 of treatment, an increase in fatigue levels was expected, which did not happen; they remained stable (Ben-Josef, et al. [41]). The practice of Pilates is also an excellent alternative to the conventional treatment of urinary incontinence during post-prostatectomy.

Two groups were compared during an intervention that lasted ten weeks. The results demonstrated that in both groups, there was a significant improvement in reducing urinary incontinence. This modality showed a reduction in the weight of the diaper, recovery of continence (without a diaper) and, consequently, improved quality of life (Pedriali, et al. [42]). Often called a public health strategy, sport is only sometimes included in clinical intervention plans. In this sense, a study was developed in Denmark in which men suffering from prostate cancer were instructed to practice football weekly in a community club for at least six months. The results revealed that participants showed an increase in bone density, a decrease in the number of hospital visits, a reduction in body mass index (BMI) and an improvement in mental health levels (Bjerreetal, et al. [43]). Another study reinforces that an increase in BMI throughout life results in excess weight, a risk factor already mentioned, the appearance of neoplasms and possible mortality. In this sense, and although physical activity has not always been consistently associated with the incidence of PCa, the authors highlight the importance of exercise in the intentional decision to lose weight among patients and in preventing the disease (Kruk, [44]).

Food

According to scientific evidence, climate events such as floods and hurricanes increase the contamination of water sources and agricultural spaces, involving substances that are related to the appearance of prostate cancer (Steenland & Winquist, [45]). Ethical issues related to meat production and its excessive consumption also impact the environment, making it possible to adopt more sustainable production practices or explore additional options for its consumption (Font-i- Furnols, [46]). Since meat consumption is associated with a high risk of developing urological cancers (Zuniga, et al. [38]). In the oceans, the fragmentation of discarded plastics results in microplastics that have been identified as a significant factor in decreasing reproductive health and semen quality (D’Angelo & Meccariello, [47]). For (Masko, [48]), although there is no consensus on the ideal type of diet to reduce the risk of developing the disease, a plant-based diet offers advantages for both health and the environment. In this sense, reducing animal protein intake is beneficial for health and positively impacts the environment. Studies indicate that air pollution caused by foods of animal origin contributes to 80% of the 15,900 annual deaths related to food-related material pollution (Domingo, et al. [49]).

Currently, several more sustainable options are available on the market, besides several healthier protein sources, such as quinoa, nuts, seeds, lentils, hummus and tofu (Zuniga, et al. [38]). Another example is tomatoes containing lycopene, a carotenoid molecule with antioxidant properties. Capurso & Vendemiale (2017) suggest that diets rich in lycopene can help prevent the incidence and progression of prostate cancer, as can soy-based products (Yan & Spitznagel, [50]). Although of animal origin, fish oil and flaxseed supplements as omega three are considered favorable, with fish being associated with a reduction in the mortality rate in individuals with PCa. However, some studies indicate the opposite and suggest that eating fish can increase the risk of developing the disease. Choosing a diet rich in fruits and vegetables, preferably consumed in solid form, is advantageous because of the slower absorption of sugar. When choosing what to eat, it is essential to consider which type of food has a low level of saturated fats and a higher level of vegetable and whole-fat origin (Masko, [48]). In short, the participation of healthcare professionals is crucial to creating effective, safe and sustainable care models. It is essential to drive transformations in the system to empower patients to have more knowledge and control over their daily choices (Monsell, [51]).

Demystification of Palliative Care

Palliative care (pc) focuses on relieving pain and improving the quality of life of the patient and their family from a holistic perspective, integrating at the same level the physical, psychological, social, and spiritual dimensions of the human being (2020). However, although scientific evidence states that this resource significantly improves the quality of life of patients with PCA, they are rarely implemented at the beginning of the disease process (Sanford, [52]) in addition to the fact that the patient’s personality traits are associated with specific health care preferences, demonstrating that individuals who present a high level of neuroticism tend to be reluctant towards all forms of treatment at the end of life (lattice, et al. [53]). According to the (OPP, [54]), the psychologist working in the PC service is assigned the role of alleviating the patient’s suffering, cooperating in the construction of meaning for complex situations, as well as helping other health professionals to recognize and identify certain issues inherent to their professional practice, accompanying the patient and family, including the grieving process. Specifically for the patient, it provides support in order to adjust their thoughts about death and dying, supporting the elaboration of pending and difficult-to-dealwith issues, such as goodbyes, to regulate the patient’s expectations. moreover, above all, make him see death as a natural process of life (de queiroz ferreira, [55]). About the family or people relevant to the patient, the psychologist supports the expression of feelings and emotions, establishing channels of communication between the family, patient, and health professionals (OPP, [54]). (Rosenfeld, [56-63]) developed meaning-centered psychotherapy (pcs) in pc, designating it as an intervention to increase meaning at the end of life based on the patient’s emotional, psychological, and spiritual needs, which have an impact on quality of life. in general, this intervention appeared to be viable and acceptable, encouraging better adaptation of patients to the challenges inherent in confronting death. however, the sample had a small number of participants, and only two participants had advanced prostate cancer.

Conclusion

The studies covered in this literature review demonstrate that more and more have been invested in multidisciplinary psychological intervention plans for men with PCa, being an effective way of understanding what has worked and what can be improved, reinforcing that the planning process and development are the keys to a successful intervention. CBT is considered the most used approach; however, humanistic methods, such as TCP and PCS, are also considered. However, scientific evidence could be better, given the existence of intervention plans that include palliative care as a topic. Furthermore, according to the literature, psychological intervention plans still need to be implemented for this target audience in Portugal. Finally, this type of intervention should be comprehensive, being implemented not only in hospitals but also in community centers or day centers, considering that in both contexts, purposes come together in the same direction: the well-being of humans.

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