Pediatric Palliative Care at Home: A Prospective Study on Subcutaneous Drug Administration.

CONTEXT: The subcutaneous route is a useful alternative for drug administration in palliative care. Although there is scientific evidence on its use in adult patients, the literature in pediatric palliative care is almost nonexistent. OBJECTIVES: To describe the experience of a pediatric palliative care unit (PPCU) with in-home subcutaneous drug administration symptom control. METHODS: Prospective observational study of patients receiving home-based subcutaneous treatment administered as part of a PPCU treatment regimen over 16 months. Analysis includes demographic and clinical variables and treatment received. RESULTS: Fifty-four different subcutaneous lines were inserted in the 15 patients included, mainly in the thigh (85.2%). The median time of needle in situ was 5.5 days (range: 1-36 days). A single drug was administered in 55.7% of treatments. The most frequently used drugs were morphine chloride (82%) and midazolam (55.7%). Continuous subcutaneous infusion was the predominant administration route (96.7%), with infusion rates oscillating between 0.1 mL/h and 1.5 mL/h. A statistically significant relationship was found between the maximum infusion rate and induration onset. Of the 54 lines placed, 29 (53.7%) had an associated complication requiring line removal. The primary cause for removal was insertion-site induration (46.3%). Subcutaneous lines were mainly used to manage pain, dyspnea, and epileptic seizures. CONCLUSION: In the pediatric palliative care patients studied, the subcutaneous route is most frequently used for administering morphine and midazolam in continuous infusion. The main complication was induration, especially with longer dwell times or higher infusion rates. However, further studies are required to optimize management and prevent complications.

Puntos farmacéuticos clave de la terapia antimicrobiana parenteral domiciliaria: revisión narrativa / Pharmaceutical key points in domiciliar prenteral antimicrobian therapy: narrative review

Introducción: Los buenos resultados de la terapia intravenosa domiciliaria, la mayor complejidad de los pacientes y el aumento de presión hospitalaria provocan que cada vez que los requerimientos técnicos sobre la misma sean más exigentes. Método: De todos los principios activos se realizó una búsqueda ordenada mediante términos MESH buscando: [“principio activo” and stability], [“principio activo” and storage], [“principio activo” and solvent]. Resultados: En este artículo se detallan los aspectos técnicos críticos a la hora de plantear una estrategia de antibioterapia intravenosa a domicilio: se revisan los antimicrobianos (antibióticos, antifúngicos y antivirales) candidatos a ser administrados en el domicilio por vía intravenosa en un paciente ingresado cargo de un servicio de hospitalización a domicilio: se revisan los principios activos candidatos, la concentración a la que se debe administrar, los tiempos de infusión mínimos, las condiciones de conservación, las estabilidades máximas, los solventes compatibles más frecuentes tipo de vía en la que deberíamos administrar según las propiedades fisicoquímicas del fármaco, el dispositivo de administración y la duración prevista del tratamiento. Conclusiones: Es fundamental a la hora de plantear una terapia intravenosa antibiótica domiciliaria que los fármacos se encuentren correctamente acondicionados y seleccionados.(AU)

Introduction: The good results of home intrave-nous therapy, the greater complexity of patients and the increase in hospital pressure cause that every time the technical requirements on it are more demanding. Method: Of all drugs, a search was carried out in order using MESH terms searching: [“drug” and stability], [“drug” and storage], [“drug” and solvent]. Results: This article details the critical technical aspects when considering a home intravenous antibiotic therapy strategy: antimicrobials (an-tibiotics, antifungals and antivirals) candidates to be administered at home intravenously in an inpatient in charge of a home hospitalization service are reviewed: the candidate drugs, the concentration to be administered, the minimum infusion times, storage conditions, maximum stability, the most frequent compatible solvents and the vascular access in which we should ad-minister according to the physicochemical prop-erties of the drug, the delivery device and the expected duration of treatment. Conclusions: It is essential when considering a home antibiotic intravenous therapy that the drugs are correctly conditioned and selected.(AU)

Atención a pacientes con úlceras y heridas en un servicio de hospitalización a domicilio: estudio retrospectivo / Care for patients with ulcers and wounds in a home hospitalization service: a retrospective study

Introducción: Las Unidades de Hospitalización a Domicilio (HAD) atienden en sus domicilios a pacientes que precisan tratamientos de intensidad hospitalaria, que incluyen medicaciones endovenosas y cuidados de alta complejidad no asumibles por otro nivel asistencial.Objetivos:Cuantificar y describir los pacientes con úlceras y heridas en la HAD del Hospital Dos de Maig (HDM) de Barcelona durante de diez años.Método:Estudio retrospectivo y análisis de los pacientes con heridas llevados por la Unidad de Hospitalización a Domicilio del Hospital Dos de Mayo de Barcelona durante el periodo 2011-202. Variables recogidas: número de pacientes; estancias media y totales; etiología (presión, vasculares, pie diabético, complicaciones de heridas quirúrgicas, lesiones traumáticas con o sin celulitis); pacientes con tratamiento endovenoso y destino al alta.Resultados:1111 pacientes (12% del total ingresaron por úlceras o heridas o complicaciones de las mismas, con una estancia media de 14 días de ingreso (rango 1-79), sumando un total de 16.254 estancias. Etiologías: 447 complicaciones de heridas quirúrgicas, 252 úlceras vasculares y 187 úlceras por presión, 95 heridas traumáticas, hematomas o picaduras con celulitis, 56 amputaciones con complicación o dehiscencia, 54 heridas en pie diabético sin intervención quirúrgica y 20 post operatorios sin complicación en la herida. El 92% de pacientes requirieron tratamiento endovenoso. El 2% de los pacientes precisó ingreso imprevisto por complicaciones.Conclusiones:Las úlceras y heridas complejas con criterio de ingreso hospitalario son un motivo frecuente de atención en una HAD, con buenos resultados al alta. (AU)

Introduction: Hospital at Home Units (HAH) attend Patients than are hospitalized in their homes to receive intravenous treatments or complex wounds healing than cannot be done for another assistant level than hospital.Objectives:Demonstrate that wounds and ulcers have been treated in Hospital at Home services of Hospital Dos de Mayo(HDM) in Barcelona and record what type of injuries have been treated last 10 years.Method:Retrospective study and analysis of all the injuries taken by Home Hospitalization Unit of HDM in Barcelona during the period 2011-2020; variables collected: number of patients, average and total stays and types of wounds according to the following classification: pressure ulcers, vascular ulcers, diabetic foot, surgical wound complications, post-surgical intervention injuries without complications and traumatic injuries with or without cellulite; patients with intravenous treatment and destination at dischargeResults:The 12% of patients in HAH 1111(9327) were entered with a diagnosis related injuries or complications thereof, 14 average stay (1-79). They add up to a total of 16.254 stays. Classifications of wounds: 56 amputations with complication or dehiscence, 95 traumatic wounds and/or bruises with cellulitis, 447 complications of surgical injuries from trauma or general surgery, 54 diabetic foot wounds without surgical intervention, 20 post operative wounds without complications in the wound, 252 vascular ulcers and 187 pressure ulcers. The 8% don’t take intravenous treatment and only 2% required unexpected admission due to complications.Conclusions:Ulcers and complex wounds with criteria for hospital admission are a frequent reason for care in an HAD, with good results at discharge. (AU)

COVID-19 in New South Wales children during 2021: severity and clinical spectrum.

OBJECTIVES: To describe the severity and clinical spectrum of coronavirus disease 2019 (COVID-19) in children during the 2021 New South Wales outbreak of the Delta variant of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). DESIGN, SETTING: Prospective cohort study in three metropolitan Sydney local health districts, 1 June - 31 October 2021. PARTICIPANTS: Children under 16 years of age with positive SARS-CoV-2 nucleic acid test results admitted to hospital or managed by the Sydney Children's Hospital Network (SCHN) virtual care team. MAIN OUTCOME MEASURES: Age-specific SARS-CoV-2 infection frequency, overall and separately for SCHN virtual and hospital patients; rates of medical and social reason admissions, intensive care admissions, and paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 per 100 SARS-CoV-2 infections; demographic and clinical factors that influenced likelihood of hospital admission. RESULTS: A total of 17 474 SARS-CoV-2 infections in children under 16 were recorded in NSW, of whom 11 985 (68.6%) received SCHN-coordinated care, including 459 admitted to SCHN hospitals: 165 for medical reasons (1.38 [95% CI, 1.17-1.59] per 100 infections), including 15 admitted to intensive care, and 294 (under 18 years of age) for social reasons (2.45 [95% CI, 2.18-2.73] per 100 infections). In an analysis that included all children admitted to hospital and a random sample of those managed by the virtual team, having another medical condition (adjusted odds ratio [aOR], 7.42; 95% CI, 3.08-19.3) was associated with increased likelihood of medical admission; in univariate analyses, non-asthmatic chronic respiratory disease was associated with greater (OR, 9.21; 95% CI, 1.61-174) and asthma/viral induced wheeze with lower likelihood of admission (OR, 0.38; 95% CI, 0.18-0.78). The likelihood of admission for medical reasons declined from infancy to 5-11 years, but rose again for those aged 12-15 years. Sex and Indigenous status did not influence the likelihood of admission. CONCLUSION: Most SARS-CoV-2 infections (Delta variant) in children were asymptomatic or associated with mild disease. Hospitalisation was relatively infrequent, and most common for infants, adolescents, and children with other medical conditions. More children were hospitalised for social than for medical reasons.

Análisis bibliométrico de la documentación científica existente, en la base de datos MEDLINE, sobre la Coronavirus Disease 2019 (COVID-19) relacionada con los cuidados domiciliarios: los primeros 6 meses desde de la declaración de la pandemia / Bibliometrical Analysis of the scientific production in MEDLINE database related to Coronavirus Disease 2019 (COVID-19) and home care: first 6 months since pandemic was declared

Objetivo: Analizar y caracterizar, mediante técnica bibliométrica, la documentación científica existente en la base de datos bibliográfica MEDLINE sobre la Coronavirus Disease 2019 (COVID-19) relacionada con los cuidados domiciliarios.Método: Estudio descriptivo transversal. Los datos se obtuvieron de la base de datos MEDLINE, a través de PubMed, interrogando los términos a estudio en los campos de descriptores, título y resumen; fecha final de búsqueda 31 enero de 2021.Resultados: Evolución de la producción científica creciente (R2 = 0,8). El número de originales fue de 24 (20,5%), con Índice de Cooperación de 4,8 ± 0,3 autores/artículo. El idioma predominante fue el inglés con 103 (88,0%) referencias. El núcleo de Bradford lo constituyeron 9 (12,0%) revistas. La indización mayor sobre hospitalización a domicilio se constató en 28 (23,9%) de los documentos.Conclusiones: La producción analizada presentaba un crecimiento lineal directo, siendo el artículo original la principal tipología documental que principalmente estuvo redactada en inglés y presentó filiación estadounidense. Se probó un buen índice de colaboración, si bien el tema de hospitalización domiciliaria no estuvo mayoritariamente representado.(AU)

Objective: Analyze and characterize through bibliometrical technique the scientific produc-tion in MEDLINE database related to Coronavi-rus Disease 2019 (COVID-19) and home care.Method: Descriptive cross-sectional study. The data were obtained from MEDLINE database, through PubMed, questioning the terms under study in the fields of descriptors, title and ab-stract. Search end date January 31, 2021.Results: Evolution of growing scientific produc-tion (R2 = 0.8). The number of originals was 24 (20.5%), with a Cooperation Index of 4.8 ± 0.3 authors / article. The predominant language was English with 103 (88.0%) references. The core of Bradford was made up of 9 (12.0%) journals. The highest indexation on home hospitalization was found in 28 (23.9%) of the documents.Conclusions: The analyzed production showed a direct linear growth. The original article was the main documentary typology, being written mainly in English and with American affiliation. A good collaboration index was tested, although the issue of home hospitalization was not repre-sented in the majority.(AU)

Primera transfusión extrahospitalaria en Aragón a paciente COVID-19 / First outpatient blood transfusion in a COVID-19 patient in Aragon

Caso clínico, de una paciente, en el cual se realizó una transfusión fuera del entorno hospitalario. Tras una revisión bibliográfica narrativa sobre la hospitalización a domicilio y las transfusiones intra y extrahospitalarias, se describe el caso clínico incluyendo anamnesis del paciente, justificación del tratamiento elegido y la evolución posterior. Después de la experiencia se pudo afirmar que, mediante la colaboración de un equipo multidisciplinar, es posible realizar transfusiones en medio extrahospitalario cumpliendo todos los protocolos y sin dejar de lado la seguridad para el paciente. La buena evolución de la paciente evidenció la importancia del ambiente. Fue beneficioso para la salud tanto física, como mental, un entorno extrahospitalario, logrando una atención médica y unos cuidados de enfermería de calidad y de menor coste para un sistema sanitario ya sobrecargado. Resaltar que la atención domiciliaria permitió a los pacientes crónicos pluripatológicos una mayor autonomía, ya que están en un ambiente controlado por ellos.(AU)

Patient’s clinical case, who was blood transfused in an outpatient environment. A narrative bibliographical review has been done about outpatient hospital care and a blood transfusion done in a hospital and outpatient blood transfusion. The clinical case has been explained including the patient’s medical history, the treatment that has been chosen and clinical progress.According to the experience, it is possible to affirm that blood transfusions can be done in an outpatient environment with the support of a multidisciplinary team, following protocols and basing the transfusion on the patient’s safety.The positive clinical progress evidenced how important it is to be in a good environment.The outpatient care improved the physical and mental health, provided a quality doctors and nurses care and reduced the cost to a health system that is already overcharged. To be highlighted, the outpatient care helped the chronic patients to develop a better autonomy due to the fact that they are in an environment where they are in charge.(AU)

Sevoflurane topical analgesia for intractable pain with suicidal ideation.

Proper symptom management to improve quality of dying is mandatory in palliative care patients. Home-based control of pain caused by leg ulcers is challenging, especially when the pain is severe and refractory to conventional analgesics, the patient is intolerant to opioids and refuses invasive measures. This was the case for an 87-year-old woman under oncological palliative care who suffered from a leg ulcer causing refractory pain, which produced suicidal ideation. Leg amputation was indicated, but she had signed a living will refusing any invasive measures. After obtaining written informed consent, sevoflurane was applied topically on the ulcer, which resulted in a rapid and long-lasting reduction of pain. Daily self-administration of sevoflurane successfully controlled the wound pain and the patient abandoned her suicidal ideation, the wound healed 35 days later, and her quality of dying improved remarkably. Topical sevoflurane deserves further research on ulcers of vascular and also neoplastic aetiology.

There's No (Treatment) Place Like Home.

David Levine, MD, of Boston's Brigham and Women's hospital, is spearheading a program in which hospital level care is delivered to patients' homes. It's a research project for now. Eligible candidates who decide to participate are randomly assigned either to an inpatient-care control group or to Levine's "Home Hospital."

Hospital at Home care for older patients with cognitive impairment: a protocol for a randomised controlled feasibility trial.

INTRODUCTION: An acute hospital admission is a stressful life event for older people, particularly for those with cognitive impairment. The hospitalisation is often complicated by hospital-associated geriatric syndromes, including delirium and functional loss, leading to functional decline and nursing home admission. Hospital at Home care aims to avoid hospitalisation-associated adverse outcomes in older patients with cognitive impairment by providing hospital care in the patient's own environment. METHODS AND ANALYSIS: This randomised, non-blinded feasibility trial aims to assess the feasibility of conducting a randomised controlled trial in terms of the recruitment, use and acceptability of Hospital at Home care for older patients with cognitive impairment. The quality of care will be evaluated and the advantages and disadvantages of the Hospital at Home care programme compared with usual hospital care. Eligible patients will be randomised either to Hospital at Home care in their own environment or usual hospital care. The intervention consists of hospital level care provided at patients' homes, including visits from healthcare professionals, diagnostics (laboratory tests, blood cultures) and treatment. The control group will receive usual hospital care. Measurements will be conducted at baseline, during admission, at discharge and at 3 and 6 months after the baseline assessment. ETHICS AND DISSEMINATION: Institutional ethics approval has been granted. The findings will be disseminated through public lectures, professional and scientific conferences, as well as peer-reviewed journal articles. The study findings will contribute to knowledge on the implementation of Hospital at Home care for older patients with cognitive disorders. The results will be used to inform and support strategies to deliver eligible care to older patients with cognitive impairment. TRIAL REGISTRATION NUMBER: e020313; Pre-results.

Atuação do enfermeiro na atenção domiciliar: uma revisão integrativa da literatura / Actuación del enfermero en atención domiciliaria: una revisión integrativa de la literatura / Nursing practice in home care: an integrative literature review

RESUMO Objetivo: analisar a produção científica acerca da atuação do enfermeiro na atenção domiciliar em saúde. Método: realizou-se uma revisão integrativa da literatura por meio de consulta às bases de dados LILACS, BDENF, IBECS e MEDLINE. Foram incluídos estudos em espanhol, inglês e português, não delimitando data de publicação. Resultados: analisados 48 artigos, identificou-se que a atuação do enfermeiro na atenção domiciliar possui complexidade e diversidade de ações com uso de tecnologias leves, leve-duras especialmente, e duras. Destaca-se que desafios relacionados ao processo formativo para a atenção domiciliar estão relatados na literatura. O enfermeiro utiliza conhecimento experiencial e recomendações científicas aliados à reflexão na prática. Conclusão: a atuação do enfermeiro no espaço domiciliar é fundamental e ampla. As ações relacionais e educacionais se destacam, sendo necessárias inclusive nos cuidados técnicos, predominando a necessidade de formação para a atenção domiciliar.

RESUMEN Objetivo: analizar la producción científica sobre la actuación del enfermero en atención domiciliaria de salud. Método: se realizó revisión integrativa de la literatura mediante consulta de las bases de datos LILACS, BDENF, IBECS y MEDLINE. Fueron incluidos estudios en español, inglés y portugués, sin delimitar la fecha de publicación. Resultados: analizados 48 artículos, se identificó que la actuación del enfermero en atención domiciliaria posee complejidad y diversidad de acciones, con uso de tecnologías blandas, blandas-duras (especialmente) y duras. Se destaca que los desafíos relacionados al proceso formativo para atención domiciliaria están narrados en la literatura. El enfermero utiliza conocimiento empírico y recomendaciones científicas, aliados a la reflexión en la práctica. Conclusión: la actuación del enfermero en el ámbito domiciliario es amplia y fundamental. Las acciones relacionales y educativas se destacan, siendo necesarias incluso en los cuidados técnicos, manifestándose la necesidad de formación para atención domiciliaria.

ABSTRACT Objective: analyze scientific production on nursing practice in home care. Method: integrative review employing databases LILACS, BDENF, IBECS, and MEDLINE. Studies in Spanish, English, and Portuguese were included, regardless of publishing date. Results: after analyzing 48 articles, it was found that nursing practice in home care is complex, employing a multitude of actions by using three technologies: soft; soft-hard especially; and hard. Challenges related to the home-care training process are reported in the literature. Nurses use knowledge from their experience and scientific recommendations in conjunction with their reflections on the practice. Conclusion: home nursing practice is fundamental and widespread. Relational and educational actions stand out as necessary even in technical care, with a predominant need for home-care training.

[Analysis of the Cochrane Review: Early Discharge Hospital at Home. Cochrane Database Syst Rev. 2017;6:CD000356.] / Análise da Revisão Cochrane: Alta Hospitalar Precoce para Hospitalização Domiciliária. Cochrane Database Syst Rev. 2017;6:CD000356.

Hospital at home is a service that provides active treatment by healthcare professionals in the patient's home for a condition that otherwise would require acute hospital in-patient care. However, the clinical bene t of this intervention and its effect on health costs are not established. This Cochrane systematic review aimed to assess the effectiveness and costs of managing patients with hospital at home compared with inpatient hospital care. A systematic review of the literature was carried out by searching the following databases to 9 January 2017: Cochrane Effective Practice and Organization of Care Group (EPOC) register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, EconLit and clinical trials registries. Thirty-two randomized trials (2 of which unpublished), including 4746 patients, were included. The present review provides insuf cient objective evidence of economic bene t (through a reduction in hospital length of stay) or improved health outcomes.

A hospitalização domiciliária é um serviço que proporciona tratamento a doentes com doença aguda no próprio domicílio, os quais noutras condições necessitariam de internamento hospitalar em enfermaria de agudos. No entanto, o benefício clínico desta intervenção e o seu efeito nos custos em saúde não se encontram estabelecidos. Esta revisão sistemática Cochrane teve como objectivo avaliar a eficácia e custos associados aos cuidados de doentes admitidos no serviço de hospitalização domiciliária em comparação com internamento hospitalar habitual. Foi realizada revisão sistemática da literatura através de pesquisa nas seguintes bases de dados - The Cochrane Effective Practice and Organisation of Care Group (EPOC) register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, e EconLit - até 9 de janeiro de 2017. Foram incluídos 32 ensaios clínicos aleatorizados (2 dos quais não publicados), incluindo 4746 doentes. A presente revisão detetou evidência insuficiente do benefício económico (através de uma redução no período de internamento hospitalar) ou melhoria dos resultados clínicos da hospitalização domiciliária.

Mobile communication technology and tablet personal computer application in family hospital bed management / 中华全科医师杂志

Family hospital bed information (FBH) system running on tablet personal computer (PC) was developed from the analysis of 36 general practitioner′s requirements.The system shared information with the hospital information system (HIS).The establishment of FHB information management system and the mode of reviewing and editing medical records,prescription and personal health record on tablet PC improved the management efficiency and quality of FHB.

Outpatient pulmonary rehabilitation - rehabilitation models and shortcomings in outpatient aftercare.

BACKGROUND: The chronic obstructive pulmonary disease (COPD) and the bronchial asthma are widespread diseases. They need long-lasting and sustainable rehabilitation. OBJECTIVES: The goal of this HTA is to describe the present supply and the economic relevance of out-patient pulmonary rehabilitation in conjunction with its social aspects. A further target is to derivate options for actions in the health-care system and possible research necessities. METHODS: Relevant publications are identified by means of a structured search in 37 database accessed through the German Institute of Medical Documentation and Information (DIMDI). In addition a manual search of identified reference lists has been done. The present report includes German and English literature published from 2004 to 2009. The methodological quality was assessed by two independent researchers according to pre-defined quality criteria of evidence based medicine. RESULTS: Among 860 publications 31 medical studies, four economic studies and 13 ethical studies meet the inclusion criteria. The studies cover rehabilitation programmes in 19 countries. The majority of them has a high level of evidence (1A to 2C). The pulmonary rehabilitation programmes differ by the setting (in-patient, out-patient, in-home, community-based), by the length of intervention (from two weeks to 36 months), by the way and the frequency of intervention and by the duration of the follow-up treatment. Overall out-patient rehabilitation programmes achieve the same positive effects for COPD patients as in-patient programmes do. This is especially true for physical performance and health related quality of life. There are only a few studies dealing with asthma. Therefore, valid statements cannot be given. The results for cost-effectiveness are not distinct enough. DISCUSSION: Goals of pulmonary rehabilitation like prevention and adequate treatment of acute exacerbations, the minimisation of hospitalisation and the reduction of mortality are attained in out-patient as well as in in-patient pulmonary rehabilitation. Regarding the best frequency of training units per week or the duration and the content of a unit further research is needed. Final results for the ideal length of an in-patient rehabilitation are still missing. None of the studies deals with the analysis of the different treatment forms of a COPD which are frequently defined by an alteration of in-patient and out-patient treatments and participation in sports clubs or self-help groups. There are some other limitations of the studies. The results concerning self-management programmes are not distinct. (Self-) Selection leads to high drop-out rates. Many studies have only small sample sizes. Confounder and long-time effects are seldom researched, relevant economic evaluations do not exist The improvement of health related quality of life is primarily obtained by an improved disease management than by an improvement of a medical parameter. CONCLUSION: Out-patient pulmonary rehabilitation is as effective as in-patient pulmonary rehabilitation. But there is a critical shortage of out-patient pulmonary rehabilitation supply in Germany. Domains for further research are the evaluation of models for integrated care, the length, frequency and content of training programmes, psychiatric assessments and the cost-effectiveness of out-patient pulmonary rehabilitation.

Analysis on the community elder care in Bao'an district of Shenzhen / 中华全科医师杂志

The status of health care for elderly in 110 community health service (CHS) centers of Bao'an District was surveyed.Data were collected from directors,health care managers and health workers in CHS centers by questionnaire.The results showed that the establishment of health file was satisfactory.but the management of health file needed to be strengthened,particularly for those required special care.The nutritional and psychological counseling should be specially focused.