Hematological Disorders.
Anemia is the most common blood disorder seen in infants and children. It is generally more prevalent in areas with poor socioeconomic conditions.
Anemia is a condition in which circulating red blood cell and hemoglobin levels are less than their normal levels (reduced numbers). Due to this, the oxygen carrying capacity of red blood cells decreases.
It is usually seen due to various reasons such as nutritional deficiency (ion, vitamin B12, or folate), chronic diseases, genetic conditions, and blood loss.
Different blood hb level according to age
Children 6 months to 6 years:= 11gm/ dl.
Children 6 years to 14 years:= 12 gm/ dl.
Above 14 years in male:=13 gm/ dl.
Female:= 12 gm/ dl.
If the hemoglobin level in a child is between 10 gm/ dl – 11 gm/ dl then it is called mild anemia.
If the hemoglobin level in a child is between 7 gm/ dl – 10 gm/ dl then it is called moderate anemia.
If the hemoglobin level in a child is less than 7 gm/dl, it is called severe anemia.
Explain the Etiology/cause of the Anemia.
Due to nutritional deficiency.
Due to chronic diseases.
Due to genetic factors.
Due to blood loss.
Due to infection.
Due to Bonemarrow disorder.
Due to vitamin deficiency.
Due to impaired production of red blood cells.
Due to excessive amount of blood loss.
Due to decreased production of red blood cells.
Explain the Clinical manifestation/ sign and symptoms of the Anemia.
feel tired,
weakness,
Pale skin, conjunctiva and mucous membrane.
Shortness of breathing,
dizziness,
headache,
Rapid and irregular heartbeat,
Cold hands and feet.
Nails become brittle.
Poor concentration.
Cognitive difficulties.
Growth and development will be delayed.
Loss of appetite.
Dizziness.
tachypnea.
Tachycardia.
Palpitation.
Diarrhea and vomiting.
Cardiac enlargement with murmur sound.
Jaundice, petechiae and ecchymosis are also present in some cases.
Hepatomegaly.
Explain the Diagnostic evaluation of the Anemia.
History taking and physical examination,
Complete blood count test.
Peripheral blood smear.
Additional blood test.
Bone marrow aspiration and biopsy.
Imaging test.
x ray
CT scan.
M.R.I.
Genetic testing.
Stool examination
Explain the management of the Anemia.
Assessing the cause of anemia in a child.
If the child’s anemic condition is due to nutritional deficiency, provide the child with adequate nutritional supplements such as iron, vitamin B12 and folate.
Providing a nutritious diet with proper iron to the child.
Providing adequate supplementary diet to the child according to nutritional deficiency.
If the child has anemic condition due to any infection or chronic disease, treat the child’s condition immediately.
If the child has the condition of severe anemia then proper blood transfusion should be done.
Monitoring the child regularly.
If the child’s anemic condition is due to excessive blood loss, stop and start intravenous infusion immediately.
To provide complete education to the child and his family members about the child’s condition, its causes, its symptoms and signs and its treatment.
To carry out all types of laboratory investigations of the child.
Screening the child regularly to prevent the child from anemic conditions.
Iron deficiency anemia is the most common nutritional and hematological disorder in infants and children. It is generally more prevalent in areas with poor socioeconomic conditions.
Iron deficiency anemia is a condition in which the production of red blood cells decreases due to deficiency of iron in children. The disease caused by deficiency of iron which helps in the production of hemoglobin is called iron deficiency anemia.
Explain the Etiology/cause of the iron deficiency anemia.
Inadequate iron storage during the intrauterine period,
prematurity,
tween baby,
maternal anemia,
Ignorance About Child Care,
poverty,
Due to some kind of disease condition viz
diarrheal disease,
Infection, malabsorption syndrome,
hookworm infestation,
Due to chronic illness,
Due to insufficient ion supply at birth.
Due to impaired ion absorption.
Due to blood loss.
Due to nutritional deficiency.
Due to chronic diseases.
Due to genetic factors.
Due to blood loss.
Due to infection.
Due to Bonemarrow disorder.
Due to vitamin deficiency.
Due to impaired production of red blood cells.
Due to excessive amount of blood loss.
Due to increased requirement of iron in the body.
Due to intensive breastfeeding.
Due to hereditary and genetic factors.
Explain the clinical manifestation/sign and symptoms of the iron deficiency anemia.
feel tired,
weakness,
Pale skin, conjunctiva and mucous membrane.
Shortness of breathing,
dizziness,
headache,
Rapid and irregular heartbeat,
Cold hands and feet.
Nails become brittle.
Poor concentration.
Cognitive difficulties.
Growth and development will be delayed.
Loss of appetite.
Dizziness.
tachypnea.
Tachycardia.
Palpitation.
Diarrhea and vomiting.
Cardiac enlargement with murmur sound.
Jaundice, petechiae and ecchymosis are also present in some cases.
Hepatomegaly.
Irritability.
Tiredness.
Atrophy of tongue papilla.
Explain the Diagnostic evaluation of the child with the iron deficiency anemia.
History taking and physical examination,
Complete blood count test.
Peripheral blood smear.
Additional blood test.
Bone marrow aspiration and biopsy.
Serum ferritin level test.
Total Iron Binding Capacity Test.
Imaging test.
x ray
CT scan.
M.R.I.
Genetic testing.
Stool examination
Explain the management of the iron deficiency anemia.
Provide ferrous sulfate 6 mg/ kg/ 24 hour 3 doses to the child.
Provide iron dextron 50 mg/ 24 hour- IM to the child.
Provide 0.4 mg/day of folic acid to children under 4 years of age.
Provide the child with vitamin B12- 30 – 100 ug, IM, SC (5 to 10 days).
Improving the dietary intake of the child, especially providing iron and protein containing food to the child.
If the child’s anemic condition is due to nutritional deficiency, provide the child with adequate nutritional supplements such as iron, vitamin B12 and folate.
Providing a nutritious diet with proper iron to the child.
Providing adequate supplementary diet to the child according to nutritional deficiency.
If the child has anemic condition due to any infection or chronic disease, treat the child’s condition immediately.
If the child has the condition of severe anemia then proper blood transfusion should be done.
Monitoring the child regularly.
If the child’s anemic condition is due to excessive blood loss, stop and start intravenous infusion immediately.
To provide complete education to the child and his family members about the child’s condition, its causes, its symptoms and signs and its treatment.
To carry out all types of laboratory investigations of the child.
Screening the child regularly to prevent the child from anemic conditions.
Advise the child to take adequate rest.
Provide proper emotional support to the child and his family members.
Properly monitoring the child’s condition including vital sign intake output chart properly recording.
Explain/Define Sickle cell Anemia.
“Sickle cell anemia” is a severe hemolytic anemia and a hereditary and genetic blood disorder that usually affects red blood cells in which the red blood cells have an abnormal sickle cell.
In this disease, red blood cells are rigid, sticky and abnormal crescent and sickle sep. The abnormal shape of these red blood cells blocks blood flow, leading to pain, organ damage, and an increased risk of infection. The capacity is also decreased.
Explain the Etiology/cause of the Sickle cell Anemia.
Due to genetic mutation.
Due to hereditary condition.
Having a family history of sickle cell disease.
Explain the Clinical manifestation/ sign and symptoms of the Sickle cell Anemia.
mild jaundice,
fever,
headache,
feel tired,
weakness,
Pale skin, conjunctiva and mucous membrane.
Shortness of breathing,
dizziness,
Vision problems,
Leg ulcers,
Absence of speech,
Having pain episodes,
headache,
Rapid and irregular heartbeat,
Cold hands and feet.
Nails become brittle.
Poor concentration.
Cognitive difficulties.
Growth and development will be delayed.
Loss of appetite.
Dizziness.
tachypnea.
Tachycardia.
Palpitation.
Diarrhea and vomiting.
Cardiac enlargement with murmur sound.
Jaundice, petechiae and ecchymosis are also present in some cases.
Hepatomegaly.
Irritability.
Tiredness.
Pneumonia.
Traumatic rupture of an enlarged spleen.
Explain the Diagnostic evaluation of the child with the Sickle cell Anemia.
History taking and physical examination,
Complete blood count test.
Peripheral blood smear.
Additional blood test.
Hemoglobin solubility test,
Bone marrow aspiration and biopsy.
Serum ferritin level test.
Total Iron Binding Capacity Test.
Genetic testing.
Explain the management of the Sickle cell Anemia.
Regular health super vision of the child.
Provide adequate hydroxyurea medication to the child.
Properly maintain the child’s hydration status.
Properly maintain the child’s blood and electrolyte levels.
Provide proper antibiotic medication to the child.
Improving the dietary intake of the child, especially providing food containing iron and protein to the child.
If the child’s anemic condition is due to nutritional deficiency, provide the child with adequate nutritional supplements such as iron, vitamin B12 and folate.
Providing a nutritious diet with proper iron to the child.
Providing adequate supplementary diet to the child according to nutritional deficiency.
If the child has anemic condition due to any infection or chronic disease, treat the child’s condition immediately.
If the child has the condition of severe anemia then proper blood transfusion should be done.
Monitoring the child regularly.
If the child’s anemic condition is due to excessive blood loss, stop and start intravenous infusion immediately.
If the child has a pain condition, provide analgesic medication.
To provide complete education to the child and his family members about the child’s condition, its causes, its symptoms and signs and its treatment.
To carry out all types of laboratory investigations of the child.
Screening the child regularly to prevent the child from anemic conditions.
Advise the child to take adequate rest.
Provide proper emotional support to the child and his family members.
Properly monitoring the child’s condition including vital sign intake output chart properly recording.
Thalassemia is a group of hereditary hemolytic anemias. which is an autosomal recessive genetic disorder in which the synthesis of hemoglobin is reduced/inadequate amount of production.
Thalassemia is a genetic blood disorder in which the body does not produce sufficient amount of hemoglobin (protein in red blood cells that carry oxygen into the body). These red blood cells are destroyed in large amounts due to which the condition of anemia arises.
There are mainly two types of thalassemia.
A) Alpha Thalassemia,
B) Beta thalassemia,
A) Alpha Thalassemia,
Alpha thalassemia is caused by missing or mutated alpha chain of hemoglobin.
1) Silent Carrier
In this one or both alpha globin genes are missing or mutated but no symptoms are seen.
2)Alpha thalassemia trait
These two alpha globin genes are missing or mutated, and this causes a condition of mild anemia, with mild symptoms such as fatigue or pale skin.
3) Hemoglobin H disease
In this, the condition of moderate to severe anemia arises due to missing and mutation of three alpha globin chains. It has more pronounced anemia, jaundice,
Enlarged spleen and other symptoms are seen.
4) Alpha thalassemia major
In this, all i.e. all four alpha globin genes are missing and severely mutated. Due to this, severe anemia and other health problems can be seen.
B) Beta thalassemia,
Beta thalassemia is caused by missing or mutated beta chain of hemoglobin.
1) Beta thalassemia trait
In this, a beta globin gene is missing and mutated, the child is usually mild and no other symptoms are seen.
2) Beta thalassemia intermedia
In this two beta globin genes are affected to a moderate degree, symptoms are very wide. Due to this condition of mild to severe anemia is seen. Sometimes it also requires transfusion.
3) Beta thalassemia major (Culis anemia)
In this both beta globin genes are severely affected. Due to Hina the condition of severe anemia arises. In this, transfusion is a life-long requirement starting from childhood.
Another classification of the thalassemia
1) Thalassemia Major,
2) Thalassemia intermedia,
3) Thalassemia minor
Thalassemia major is the most severe form of thalassemia.
It occurs when a child inherits two mutated beta globin genes, one from both parents. This results in a significant reduction or absence of the beta globin chain, a condition of severe anemia.
Children with thalassemia major require lifelong blood transfusions from childhood to maintain hemoglobin levels and prevent complications.
Without treatment, thalassemia major can lead to growth delay, organ damage and bone problems and other health related conditions.
Thalassemia intermedia is an intermediate form of thalassemia, less severe than thalassemia major but more severe than thalassemia minor. A child with thalassemia intermedia has two mutated beta globin genes, but the degree of blackness varies.
Symptoms can range from mild to moderate anemia, and some children may even require blood transfusions to manage symptoms.
The need for treatment varies according to the severity of symptoms in a child with thalassemia intermedia. Children with thalassemia intermedia may develop complications such as bone deformities, enlarged spleen, and gallstones, but these are usually less severe than with thalassemia major.
Thalassemia minor, also known as thalassemia trait, is the mildest form of thalassemia. It occurs when a child inherits a mutated beta globin gene from one parent and a normal beta globin gene from the other parent.
A child with thalassemia minor usually has no symptoms or only mild symptoms of anemia.
Thalassemia minor carriers usually have slightly lower hemoglobin levels than normal, but they usually do not require treatment. However, carriers of thalassemia minor can pass the gene mutation on to their children.
Explain the Etiology/ Cause of the thalassemia.
(State the cause of Thalassemia)
Due to genetic mutation,
Due to impairment in alpha globin and beta globin.
Being a family history.
Explain the clinical manifestation / sign and symptoms of the thalassemia.
(State the symptoms and signs of Thalassemia).
feel tired,
Pale skin, conjunctiva and mucous membrane.
Shortness of breath,
Spleen and liver enlargement (hepatosplenomegaly),
jaundice,
Growth and development are delayed,
Bone abnormalities,
heart problem,
Endocrine complications,
Getting infected.
Loss of appetite (anorexia),
Poor feeding habit,
Abdomen is distended,
Failure to Thrive,
Facial features – Upper maxilla hypertrophoid, exposing of upper teeth, depressed nasal bridge,
mal occlusion of teeth,
lymphadenopathy or hypogonadism,
Osteoporosis of
Metacarpals and Metatarsals.
Recurrent respiratory infection,
lymph node enlargement,
Poor nutritional status.
Explain the diagnostic evaluation of the thalassemia.
(State diagnostic evaluation of thalassemia).
History taking and physical examination,
Complete blood count test,
Hemoglobin electrophoresis,
Peripheral blood smear,
Iron Studies,
genetic testing,
Bone marrow examination,
common
Serum bilirubin test,
Serum iron level,
Bone marrow studies,
Osmotic fragility test,
radiological findings,
Explain the management of the thalassemia.
(Inform management of thalassemia).
The child may require repeated blood transfusions. A child needs blood transfusion starting from early childhood and throughout the throwout life.
Provide proper iron chelating therapy to the child. Long-term transfusions to the child may lead to iron overload. Due to which iron chelatin therapy is provided to the child to prevent this condition.
This involves the involvement of iron chelating therapy (deferoxamide, deferiprone, deferasirox).
Providing proper folic acid supplementation to the child.
Performing bone marrow transplantation on the child.
Providing proper gene therapy to the child.
To provide properly supportive care to the child.
Explain the Nursing Management of the thalassemia.
(Inform nursing management of thalassemia).
Provide complete education to the patient about the condition, its causes, symptoms and signs, and its treatment.
Continuous monitoring of the child.
Proper blood transfusion to the child.
Assess whether the child has any reaction at the time of blood transfusion or not.
Regular health super vision of the child.
Properly maintain the child’s hydration status.
Properly maintain the child’s blood and electrolyte levels.
Provide proper antibiotic medication to the child.
Improving the dietary intake of the child, especially providing food containing iron and protein to the child.
If the child’s anemic condition is due to nutritional deficiency, provide the child with adequate nutritional supplements such as iron, vitamin B12 and folate.
Providing a nutritious diet with proper iron to the child.
Providing adequate supplementary diet to the child according to nutritional deficiency.
If the child has anemic condition due to any infection or chronic disease, treat the child’s condition immediately.
If the child has the condition of severe anemia then proper blood transfusion should be done.
Monitoring the child regularly.
If the child’s anemic condition is due to excessive blood loss, stop and start intravenous infusion immediately.
If the child has a pain condition, provide analgesic medication.
To provide complete education to the child and his family members about the child’s condition, its causes, its symptoms and signs and its treatment.
To carry out all types of laboratory investigations of the child.
Screening the child regularly to prevent the child from anemic conditions.
Advise the child to take adequate rest.
Provide proper emotional support to the child and his family members.
Properly monitoring the child’s condition including vital sign intake output chart properly recording.
Explain/Define Leukemia
Leukemia is the most common type of childhood malignancy, which is usually a cancer of the blood and bone marrow, characterized by persistent and uncontrolled production of immature and abnormal WBCs.
These diseases are usually caused by abnormal proliferation and maturation of bone marrow, interfering with the production of normal red blood cells, white blood cells and platelets. Leukemia is a major neoplastic disease occurring in childhood.
Explain the Classification of the Leukemia
There are two total classifications of leukemia.
1) Acute leukemia,
2) Chronic leukemia
1) Acute leukemia,
Acute leukemia is the most common type of leukemia seen in children. In which the rapid production of immature white blood cells takes place. which are called lymphoblasts.
There are two other types of acute leukemia.
a) Acute lymphogenous leukemia,
b) Acute nonlymphogenous leukemia,
Acute myeloid leukemia,
Myelomonocytic leukemia,
Acute monocytic leukemia.
2) Chronic leukemia
Chronic leukemia is a rare condition seen in children. In which white blood cells are slowly over produced.
There are two other types of chronic leukemia.
1). Chronic myeloid leukemia in children,
juvenile type,
Adult type.
2). Chronic lymphocytic leukemia.
Explain the Etiology/cause of the Leukemia
Due to genetic factors,
Due to environmental factors,
Due to chromosomal abnormalities,
Due to previous cancer treatment,
Due to immune system disorders,
Due to lifestyle factor,
Due to family history,
due to virus,
due to radiation,
Due to hereditary causes,
In children who have the condition of Down syndrome and Turner syndrome.
Explain the clinical manifestation / sign and symptoms of the Leukemia
feel tired,
Fever,
Getting infected frequently,
Easy bruising and bleeding,
bone pain,
lymph node enlargement,
weight loss,
pale skin,
Night sweating,
become anemic,
thrombocytopenia,
purpura,
ecchymosis,
Gastrointestinal haemorrhage,
Cerebral hemorrhage,
coming to palness,
Pain in bones and joints,
Widening of cranial sutures due to increased intracranial pressure,
not hungry,
malays,
weakness,
Activity Level Degree,
weight loss,
muscle wasting,
abdominal pain,
Explain the Diagnostic evaluation of the Leukemia.
History taking and physical examination,
Peripheral Blood Examination,
Complete blood count test,
W.B.C.Count Test,
Chest x-ray,
C.S.F Studies,
Blood examination.
Explain the Management of the Leukemia
Providing proper chemotherapy medication to the child.
Properly providing radiation therapy along with chemotherapy to the child.
Proper stem cells transplantation of the child.
If the child has a condition of infection, treat it properly.
If the child has a pain condition, provide analgesic medication to the child to treat it.
Providing proper nutritional support to the child.
Continuous monitoring of the child.
Provide proper emotional support to reduce the anxiety of the child and his family members.
Maintain proper aseptic technique while handling the child.
Provide properly prescribed antibiotic medication to the child.
Continuous vital sign monitoring of the child.
Properly maintain intake output chart of child.
Keeping the child’s body temperature properly maintained.
To provide complete education to the child’s parents about the child’s condition, its causes, symptoms and signs and its treatment.
Providing properly prescribed medication to the child.
Advising parents of child to take regular follow up.
Hemophilia is an inherited bleeding disorder usually caused by a deficiency of plasma coagulation factors (factors 8, 9, and 11).
It is usually found in high amounts in mail. In which excessive bleeding occurs and blood clotting is poor.
Explain the Classification of the Hemophilia.
There are total 3 classifications of hemophilia.
1) Hemophilia A,
2) Hemophilia B,
3) Hemophilia C.
1) Hemophilia A
Hemophilia A is caused by a deficiency of factor VII(8).
2) Hemophilia B,
Hemophilia B is usually caused by factor IX(9) deficiency.
3) Hemophilia C.
Hemophilia C is caused by a deficiency of factor Xi (11).
Explain the Clinical manifestation/ Sign and symptoms of the Hemophilia.
Excessive bruising.
Bleeding after injury.
Joint bleeding.
Bleeding from muscles and soft tissues.
Passage of blood in urine and stool.
Nose bleeding (epistaxis).
Oral bleeding.
Intracranial bleeding.
Bleeding from the gastrointestinal tract.
Hematuria.
Easy bruising.
Explain the Diagnostic evaluation of the Hemophilia.
History taking and physical examination,
Clotting Factor Assay,
Coagulation studies,
genetic testing,
factor activity test,
joint imaging,
Comprehensive Evaluation.
Assess the clotting time,
X-ray of the affected joint,
Gene Analysis,
Explain the Management of the Hemophilia.
Provide proper clotting factor replacement therapy to the child.
If the child has the condition of hemophilia A, provide clotting factor 8.
If the child has the condition of hemophilia B, provide clotting factor 9.
If the child has the condition of hemophilia C, provide clotting factor 11.
Providing proper blood transfusion to the child.
Provide the child with anti-fibrinolytic medication such as aminocaproic acid and tenexamic acid to prevent mucosal bleeding.
Advise the child to take proper rest.
Immobilize the child’s joint.
Applying local cold to the child.
Analgesic medication should be provided if pain persists.
Ex:= Paracetamol,
NSAIDs.
Explain the Nursing Management of the Hemophilia.
To provide complete education to the child and his family members about the child’s condition, its causes, its symptoms and signs and its treatment.
If the child has any kind of injury, apply pressure on that site for 10 to 15 minutes.
Properly immobilize the affected body part of the child.
Elevate the affected part of the child.
To provide a complete quiet environment to the child.
To monitor the child’s vital signs daily.
Providing properly prescribed medication to the child.
To provide adequate psychological support to the child.
Advising the parents to take the child for regular follow up.
Explain/Define Immune Thrombocytopenic purpura
Immune thrombocytopenic purpura was previously called “idiopathic thrombocytopenic purpura”. But now it is called “immune thrombocytopenic purpura”. In this condition, the body’s platelet count is lower than its normal level.
Platelets are cells important for blood clotting and stopping bleeding. When this platelet count is low in the body, easy bruising and bruising occurs in the body, and spontaneous hemorrhage occurs in the skin and mucus membrane.
Because of this, petechiae, ecchymosis and hematoma are also seen in the skin.
Explain the Etiology/cause of the immune Thrombocytopenic purpura
Due to autoimmune response,
Due to viral infection,
Due to genetic factors,
Due to environmental factors,
Due to impaired immune system,
Due to decreased production of platelet count,
Due to the platelet count becoming abnormal in excessive amounts,
Explain the Classification of the immune Thrombocytopenic purpura
There are two types of immune thrombocytopenic purpura.
1) Acute immune thrombocytopenic purpura,
2) Chronic immune thrombocytopenic purpura
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1) Acute immune thrombocytopenic purpura,
Acute immune thrombocytopenic purpura is most commonly seen in childhood. It is usually seen after any viral infection.
Its onset is also sudden and resolves within 6 months. Acute immune thrombocytopenic purpura is self-limiting and resolves within a few weeks and months.
2) Chronic immune thrombocytopenic purpura
Chronic immune thrombocytopenic purpura is less commonly seen in children. It is not usually caused by any viral infection.
Chronic immune thrombocytopenic purpura usually persists for more than 6 months and usually requires treatment to cure it.
Explain the Clinical manifestation/ Sign and symptoms of the immune Thrombocytopenic purpura.
Petechiae,
purpura,
Easy Bruising,
mucosal bleeding,
Excessive bleeding,
Passage of blood in stool and urine,
Easy bruising due to minor trauma,
ecchymosis,
Bleeding from mucosal surfaces such as the nose and gums,
GI bleeding,
Severe nosebleeds,
intracranial hemorrhage,
Excessive bleeding even after minor surgery.
Explain the Diagnostic evaluation of the immune Thrombocytopenic purpura.
History taking and physical examination,
blood examination,
Bonmaro Studies,
Complete blood count test,
peripheral blood smear,
Bonemarrow Aspiration,
antibody testing,
Explain the management of immune thrombocytopenic purpura.
Continuous monitoring and observation of the child.
To provide complete education to the child and his family members about the child’s condition, its causes, symptoms and signs and its treatment.
Provide education to the child’s parents to prevent injury.
Provide adequate corticosteroid medication to the child in moderate degree of immune thrombocytopenic purpura condition.
Perform platelet transfusion if the child is having severe build-up.
If necessary, provide the child with intravenous immunoglobulin therapy.
Maintain child’s hygienic condition and aseptic technique properly.
To provide a properly safe and non-harmful environment to the child.
Properly prevent child from accidental injury.
If the child has the condition of constipation, give advice to take easily digestible fiber rich diet.
To follow proper precautions while giving blood transfusion to child.
Provide education to child’s parents to avoid excessive force under the nose.
To monitor the child’s vital signs regularly.
Monitoring child’s intake output chart regularly.
Properly assess whether blood is present in the child’s urine and stool or not.
To provide complete education to the child’s parents and family members about the child’s condition, its causes, symptoms and signs, and its treatment.