Disease

iNOS and arginase expressing macrophages in COPD, nitrotyrosine (product of peroxynitrite) levels have been shown to be increased in sputum macrophages of COPD patients, which are negatively correlated with their lung function. Hence, the proportion of iNOS expressing M1 macrophages and arginase expressing M2 macrophages are really important to the oxidative/nitrosative environment of the lung (Vlahos and Bozinovski, 2014).

There are polarization states in between associated equilibriums that could significantly effect COPD progression. To back this up, there is significant evidence showing positive results on reprogramming alveolar macrophages that have been in contact with chronic smoke showing correlations with processes within a particular set of genes inclusive of a gene known as MMP12.

Added evidence can be found for transcriptional skewing within alveolar macrophages aimed at the M2 gene profile present in smokers having a normal functioning lung that is apparent in those smokers showing a progressive development to COPD. Studies done have also provided demonstrations on the progressive down regulation of the M1 gene.

This may seem paradoxical towards increased expressions being observed in pro-inflammatory mediators within COPD. Because of this, we can conclude that there is a certainty of urgency when it comes to better defining significant contributions of the M1 and M2 macrophages due to there being evidence being developed sowing that both populations for sure exits in COPD airways.

An equally critical consideration in COPD is one that observed in the interaction seen between macrophages and T cell subsets. There are speculations stating that T cells are indeed the cells in control of the polarization state within macrophages. What must be made clear is that macrophages also contain a relative T cell biology; this is because T cell subsets includes CD8+ T cells, iBalt and TH17 formation that are present in COPD pathology. These macrophages have the job of regulating T cells biology remains being cleared up (Vlahos and Bozinovski, 2014).

When M2 skewed airway macrophages are accumulated, it is thought to be impaired resolution processes that normally would turn off inflammation and renew lung homeostasis. Non-phlogistric phagocytosis stimulation is crucial when it comes to the resolving of inflammation, the oxidant-dependent impairment of efferocytic clearance of damaged tissue may provide maintenance function in M2 macrophages with persons with COPD.

With the introduction of CD163 which is generally known as a marker for M2-alternatively activated macrophages that are involved in wound-healing, CD163 positive macrophages are most present in the BAL area of current and ex-smokers with COPD. CD163 has the capability of mounting a chief defence mechanism to protect the lung due to it functioning as a scavenger receptor; this in turn promotes degradation of HbHp complexes and signalling that activate expression of heme-oxygenase-1 (HO-1).

The tenacity of HO-1 in COPD airways is in accordance with an environment where there are great amounts of oxidative stress and a deficiency in the resolution of inflammation. The mediators that induce expression of M2 markers in COPD have not been comprehensively characterized.

Interleukin-10 (IL-10) is a potent inducer of CD163 expression in human monocytes; however, there is also data available that indicates that the level of IL-10 positive macrophages is reduced in COPD. There is an alternate mediator that been tested and proved to potently induces expressions of CD163 within human monocyte-derived macrophages, and is known as serum amyloid A (SAA).

SAA is a main acute phase reactant that only now have been found to show promise in COPD lungs, where its level correspond with neutrophilic inflammation. SAA is known to target the ALX/FPR2 receptor and oppose the actions of pro-resolving ligands such as LipoxinA4, which normally stimulate non-phlogistic clearance pathways.

Additionally with respect to CD163, SAA also possess the ability to stimulate the expression of the TH17 polarizing cytokines, IL-6, and IL-1β in monocyte-derived macrophages, and neutralization of IL-17A expression suppressed neutrophil airway inflammation stimulated by SAA. Thus, the tenacity of host defence mediators such as SAA have the ability to continue alternative macrophage populations in COPD airways that not only express M2 markers of wound repair, but also markers of acute inflammation (Vlahos and Bozinovski, 2014).

It is worth mentioning that oxidative stress, cigarette smoke and airway inflammatory microenvironment all show a direct effect on alveolar macrophages phenotype in COPD that shows an increase in M1 and M2 population. COPD pathology process is conducted by a ratio of, macrophages that are found in the inflamed environment. Macrophages that are known as M1 macrophages can move along the oxidative stress and inflammatory process.

Also, excessive oxidative is known to have negative effects on resolution mechanisms that includes macrophage mediated phagocytosis and efferocytosis. This leads to colonization and exacerbation within patients suffering from COPD. Thus, with the emergence of M2 macrophages, they can help to deleterious lung damage by the increase and expression of M2 related genes and also with excessive protease production of MMP-9 and 12 markers (Vlahos and Bozinovski, 2014).

Conclusion

With all the studies that have been concluded, there is now evidence to conclude that macrophages present in patients with COPD not only show an increase in numbers, but there is also a difference in their function when they are compared to healthy persons or smokers with normal lung function.

Thus, it should be noted that elevated expressions of proinflammatory mediators and effector molecules are both characteristic in COPD patients and are closely followed by a decrease in phagocytosis within respiratory pathogens and apoptotic cells. The mechanisms mentioned above may have a direct relationship in the inflammation and tissue injury that can be observed in patients with COPD.

Alveolar macrophages conduct the task of coordinating efficiently clearing any inhaled irritants and microbes in an effort the reduce inflammation. Added to this is the efferocytic activity caused by alveolar macrophages involved in the clearing of cells and tissue in the wake of any injury and infection.

There is an inflammatory persistence and inability to efficiently and effectively get rid of damaged tissues and exhausted immune cells, namely neutrophils, which may be caused by excessive stress that has a negative effect on the phagocytic capacity of alveolar macrophages.

Now, it would be worth mentioning that the presence of airway macrophages can also show a unique phenotype that is complementary with the inclusion of M2 related genes. This gene is most likely to perform its function by responding to any damage to tissues. So, the maintenance of such subpopulation may indeed have a positive effect on the deleterious remodelling within COPD.

There is a critical role to be played by alveolar macrophages when it comes to orchestrating inflammatory to chronic obstructive pulmonary disease (COPD). There is a great increase in the amount of alveolar macrophages present in the lungs of patients suffering with COPD.

This increase in alveolar macrophage numbers is as a result of the increase in recruitment, proliferation and survival. Inflammatory mediators along with oxidants, proteins and proteinases are all secreted by alveolar macrophages as part of a response to coming into contact with smoke extract along with other stimuli.

These products mentioned above are amplified in patients with chronic obstructive pulmonary disease that sees and increase in the secretion of these products that are in direct relation to defective histone deacetylase-2. This can also play a part in the resistance of steroid in the cells of COPD patients.

COPD is the fifth driving reason for death in the UK and.the.fourth.in the world. It is relied upon to ascend to the third position by 2020. It is assessed that more than 3 million individuals devour the ailment in the UK, with 2 million having undiscovered COPD (National Clinical Guideline Center, 2010). (15)

The pathophysiology of chronic obstructive pulmonary disease (COPD) is complex and can be credited to different parts: mucociliary brokenness aviation route aggravation and auxiliary changes all adding to the advancement of wind current constraint, just as a significant foundational segment (3).

Developed mucous organs cause hypersecretion of bodily fluid and the squamous metaplasia of epithelial cells brings about ciliary brokenness. These are normally the main physiological variations from the norm in COPD.

During pregnancy, the measure of air entering and leaving the lungs.increases.by 30-half, and breathing rate increments marginally. (2)

Intense intensifications of (COPD) are described by dyspnea, an expansion in the creation and purulence of sputum.

In a cross-sectional examination (2009-2010) 118 COPD patients were enlisted, 68 of them (58%) were in intense intensifications (case gathering). The others had stabile COPD and they were characterized as a control gathering.

PCT levels were seen as higher in COPD patients than in stable COPD patients, true to form. Likewise, mean PCT levels expanded especially.in cases with extreme COPD and those accepting NPPV among them (1).

Characterization of signs and symptoms

From the outset, COPD may cause no manifestations or just gentle side effects, as the illnesses progress, it might cause brevity of breath, wheezing and chest snugness particularly with work out, continuous (ceaseless) hack.

Trouble with routine exercises like weakness, weight reduction, muscle misfortune. (4)

The relationship between gastro-esophageal reflux disease (GORD) and chronic obstructive pulmonary disease (COPD) fuel has so far stayed misty. 82 patients with COPD and.40 age-coordinated controls were joined up with this examination. (4)

GORD side effects were recognized as a significant factor related with COPD intensification.

Serious respiratory pain declines after some time. Exacerbating asthma in pregnant ladies. Increasing speed of breath and heartbeat. Chest torment when relaxing. Shading around the lips, toes or turns in light blue. Pallor. (6)

Diagnosis

Once COPD is analyzed, treatment can be begun, which can back off or help keep further harm from jumping out at the lungs.

Early indications of COPD: Ongoing hack and bodily fluid generation. (5)

A breathing test called spirometry or lung work test is required to analyze COPD.

COPD presently.is evaluated utilizing a solitary estimation such as.FEV1, which, in contrast to the case with asthma, has a restricted job in ailment the board. An increasingly far-reaching arranging framework is required consolidating, for instance, age, blood vessel blood gases, dyspnea, weight record, and separation strolled, in.addition.to FEV1(6).

Non-pharmacologic management

There.is no solution for COPD, however way of life changes and treatment can enable the patient to feel to better, remain progressively dynamic and moderate malady movement.

• The smoking suspension is the best and most significant intercession accessible in the administration of COPD. COPD chance increments with smoking and ranges from 30% to half.
• Pulmonary recovery (PR).is ‘a proof-based, multidisciplinary and far-reaching mediation for patients with COPD that is intended to diminish indications, upgrade utilitarian status, increment persistent interest and lessen medicinal services costs through balancing out or turning around foundational appearances of the malady (8)
• Long-term oxygen treatment: Further proof was given by Ringbaek et al., who appeared in a Danish COPD associate that LTOT diminished affirmation rates and medical clinic days.by 23.8% and 31.2%, respectively. (10)

Consideration has been centered on the advancement of non-pharmacological procedures to improve wellbeing status and personal satisfaction and to decrease human services use and expenses by averting the recurrence and seriousness of intense intensifications of COPD. (9)

Pharmacologic Management

1. Bronchodilators: Albuterol (classification c) diminishes aviation route opposition and soothes bronchospasm.

Dose: 2 inhalations every 4 to 6 hours.

In an examination of 259 pregnant asthmatics who utilized albuterol during the primary trimester, there was no increase.in intrinsic peculiarities or antagonistic perinatal result attributable to .to the therapy. (11)

In any case, the Swedish therapeutic birth library detailed an affiliation albuterol use during pregnancy and heart surrenders in the posterity with a balanced relative danger of 1.38(95% certainty interim 1.12-1.70). (11)

2. Bronchodilators (long-acting): Salmeterol (Beta 2 agonist) and has been viewed as a drug of choice.

Dose: 1 inhalation breath multiple times every day (morning and night), the 2 dosages ought to be around 12 hours apart. (12)

One report of 65 ladies who utilized salmeterol during pregnancy portrayed three instances of untimely birth. (12)

3. Oral glucocorticoids:

Studies have proposed that there may.be an extremely little expanded danger of congenital fissure or congenital fissure in the children of moms who took oral glucocorticoid drugs during the initial 13 weeks of pregnancy.

Two investigations found a marginally expanded danger of unexpected labor, and.one study found a somewhat expanded danger of having a low birth weight infant. Nonetheless, the analysts couldn’t decide out the likelihood that these impacts were identified with the seriousness of COPD and not.to the utilization of the medication. (13)

Counselling points for the patient

Give up smoking 

Surrendering nicotine.is one of the most significant things you can accomplish for your wellbeing. Over 3 million Americans .quit each year. There are a few accommodating procedures to assist the patient with quitting. Chat with his doctor to figure out which one may.be generally supportive to him:

• Medications
• Nicotine substitution treatment
• Self-help materials

Eat right and exercise 

The brevity of breath that accompanies COPD can make it difficult to warm a decent diet. Eating a solid eating regimen and practicing is critical to keeping and improving your wellness level. Continuously converse with the doctor before beginning an eating routine or exercise plan and start gradually. (9)

• Eating little, progressively visit well-adjusted dinners.
• Using a littler plate and parts.
• Keep a jug of water with him and drink before he eat.

Get rest 

Rest is critical to by and large wellbeing, however, there are a few things that can make rest troublesome on the off chance that Patient have COPD. (10)

Take the drugs accurately 

The vast majority of COPD takes medicine.to help with standard and infrequent breathing issues. (9)

1. Taking albuterol can cause reactions to certain individuals. The most widely recognized ones are:

• Shakiness
• Fast or sporadic heartbeat
• Heart beating (palpitations)
• Chest torment
• Tremors
• Nervousness

2. The most widely recognized salmeterol reactions incorporate migraine, influenza side effects, joint or muscle torment, throat disturbance, hack, or a stuffy or runny nose.
3. The conceivable reactions of breathed in steroids incorporate an irritated throat and hack, also. as infections.in your mouth. There is likewise an expanded danger of pneumonia with long haul utilization of breathed in steroids.

Smaller conducting airways are a major site of obstruction in COPD and studies have shown that in smokers there are structural abnormalities in small airways whether they have COPD or not.

Furthermore, a correlation between severity of COPD and extent of airway occlusion by inflammatory mucus exudates is observed. Inflammation and peribronchial fibrosis contribute to the fixed obstruction of the small airways in COPD, as well as the progression of the inflammation which may result to destructed alveolar attachments on small airways outer walls.

Symptoms & Effects

COPD in general makes it much harder to breathe, symptoms usually do not appear until there is severe lung damage and they usually get worse over time especially if tobacco use or exposure continues. There are many symptoms that may be mild at first, but could progress and become constant making it even more difficult for the patient to breathe and carry out day-to-day activities. For symptoms are mild at first could be easily mistaken for a cold.

Symptoms usually begin with intermittent coughing and shortness of breath. Other early symptoms consist of occasional loss of breath that occurs during or after physical activities. Coughing although mild is still recurrent and the patients feel the need to clear their throat often especially in the morning.

After some time, symptoms can get worse and harder to ignore, as the lungs get more damaged. Latter symptoms include shortness of breath even after mild physical activity such as walking up the stairs. Wheezing is heard, especially during exhalations and the chest tightens. Coughing becomes more common and chronic whether there is mucus or not. Mucus from patient’s lungs needs to be cleared every day and the patient is more susceptible to colds, flu or other respiratory infections. Furthermore, the patients have a lack of energy.

In later stages of COPD symptoms may also consist of fatigue, swelling of feet, ankles or legs and noticeable, unexpected weight loss. The patient may experience wheezing and tightness in the chest or have excess sputum production. Some people with COPD have acute exacerbations, which are flare-ups of severe symptoms.

Very severe symptoms and signs that should be taken care of immediately include lips and fingernails cyanosis as this indicates low blood oxygen levels. Also, if the patient has trouble catching his breath or cannot talk, he feels confused, muddled or faint and he has a high heart rate medical investigation should begin immediately. However, patients may have periods of exacerbation where symptoms suddenly worsen and become more persistent even at earlier stages.

These periods usually last several days or more and can occur around five times per year especially during Winter. As the disease progresses the patient is more susceptible to heart problems, high blood pressure in lung arteries and even lung cancer. Once the diagnosis is made the patient has to make appropriate life changes in order to maintain a good quality of life. Usually early symptoms can be easily managed. As the disease progresses symptoms can be highly limiting and people with severe grade of COPD may not even be able to take care of themselves.

Furthermore, they are at high risk of respiratory infections, heart problems and lung cancer. COPD generally reduces life expectancy, although it varies from patient to patient. People with COPD who do not smoke usually have a modest reduction of life expectancy while former and current smokers have a big reduction. Another factor affecting extend of life expectancy reduction is how well the patient responds to treatment and whether serious complications can be avoided.

Complications

Nutritional Abnormalities including caloric intake, BMR, intermediate metabolism and body composition alterations are very common in COPD. About 50% of patients with severe COPD experience unexplained weight loss, while another 10-15% of patients with mild to moderate COPD may also lose weight.

The weight loss is usually skeletal muscle mass and rarely due to fat loss. However, alterations in body composition may also occur even if there is no major weight loss. Very rarely these abnormalities can be due to decreased caloric intake as this does not usually appear to be prominent in COPD patients unless they are going through exacerbation episodes. Furthermore, most COPD patients have an increased BMR which further contributes to weight loss and might be due to increased work of breathing, treatment drugs, systemic inflammation or in extreme cases tissue hypoxia.

Skeletal Muscle Dysfunction is also common, contributing to a large extent to low exercise capacity and reduced life quality. Respiratory muscles on the other hand appear to behave differently, probably due to the different conditions under the two muscle types work in these patients. Skeletal muscles are generally underused while the diaphragm is constantly working against an increased load.

Alterations of nervous system are also observed as the energy metabolism of the brain is altered in these patients and depression is highly prevalent. Autonomic nervous system may also be altered especially in those with low body weight. Dementia may also develop as low oxygen and high carbon dioxide levels can harm the brain. Finally, osteoporosis prevalence is increased in COPD as pro-inflammatory cytokines can significantly alter bone metabolism.

Another common complication is pneumonia which occurs when germs enter the lungs creating an infection. In a patient with an already weakened pulmonary system this could be fatal as it causes further inflammatory damage to the lungs leading to a chain reaction of illnesses that can weaken the lungs even further leading to a rapid deterioration and eventually respiratory failure which is found to be the most common cause of death in COPD patients.

One of the most critical complications in COPD is heart failure as it is the second most common COPD- related cause of death. People suffering from COPD have lower oxygen levels in their bloodstream and lung function which is closely related to heart function. According to American Thoracic Society the above symptoms can lead to severe pulmonary hypertension causing right-sided heart failure in 5-10% of people with advanced COPD. Furthermore, many of the symptoms of heart failure are similar or even the same to those of COPD making it difficult for the patient to recognise that they actually suffer from heart issues.

One of the most severe problems that are thought to be related to COPD is lung cancer and is also found to be the third most common cause of death in COPD patients. Both diseases have common risk factors with number one risk factor being smoking. Also both diseases are thought to be associated with some genetic predisposition.

In 2009 it was estimated that between 40-70% of people with lung cancer also had COPD and this same study concluded that COPD is a major risk factor for lung cancer. Another study carried out in 2015 suggests that COPD and lung cancer may actually be different aspects of the same disease and that COPD is a driving factor leading to lung cancer. Furthermore, there have been many cases where patients did not know they had COPD until they were diagnosed with lung cancer. However, being a COPD patient does not mean that lung cancer will develop, although it does mean there is higher risk.

COPD is the third leading cause of death in the US as doctors usually are not able to give exact prognosis after a patient is diagnosed with COPD. However, all of the above complications can be prevented with close monitoring and management of symptoms in order to slow COPD progression.

Diagnosis, Stages & Prognosis

There is no single test for COPD therefore in order to diagnose a patient with Chronic Obstructive Pulmonary Disease clinical history must be taken, carry out a physical examination and then proceed to further diagnostic testing to confirm whether the patient suffers from COPD as suspected and exclude any differential diagnosis.

Common differential diagnosis includes asthma, congestive heart failure, bronchiectasis, bronchiolitis obliterans, cystic fibrosis and tuberculosis. The main tool for diagnosis of COPD is the spirometer. Spirometry test is a simple, non-invasive and easy test that measures how well the patient’s lungs work. Furthermore, spirometry is recommended prophylactically to current or former smokers or people who have been exposed to harmful lung irritants for a long period or have alpha-1 Antitrypsin deficiency as COPD is not usually detected until in the moderate stage.

Also, it can be used to check how the disease progresses and monitor how well treatment works. During spirometry the patient has to blow all the air out of his lungs into a mouthpiece and the spirometer will calculate the amount of air blown out the first second, represented as FEV1 and the air blown out in 6 seconds or more represented as FVC. People with COPD usually have an FEV1/FVC ration less than 70% with FEV1 percentage indicating the severity of the obstruction.

Beyond spirometry complete pulmonary function testing that include lung volume, diffusing capacity and pulse oximetry measurement, may be used to distinguish COPD from asthma. Other methods of diagnosing COPD include chest X-ray which can show emphysema and also rule out other lung problems or heart failure.

A CT scan can also help detect emphysema and determine whether the patient would benefit from a surgery. Another very important test is arterial blood gases analysis which measures how well lungs transfer oxygen to blood and remove carbon dioxide and is recommended to rule out severe hypoxemia or hypercapnia in patients with more severe COPD. A blood test is also recommended to rule out any other conditions that have similar symptoms to COPD and also check whether alpha-1 antitrypsin deficiency is present, this is usually done for people who develop COPD symptoms at a younger age, before 45.

Spirometry is not only used for diagnosis but also for grading COPD. GOLD and NICE classifications are used for determining severity in order to help form a prognosis and make the best treatment plan for each patient. GOLD classification is based on FEV1 results (severity increases as FEV1 decreases), the patient’s individual symptoms and the history of acute exacerbations. GOLD classification consists of four grades from mild to very severe.

In all four stages the FEV1/FVC ratio is expected to be less than 70%. In mild stage FEV1 appears to be at least 80% of predicted value and the patient may have some symptoms. In moderate stage FEV1 is between 50% and 80% of predicted value and the patient may have chronic symptoms.

In severe stage FEV1 is expected to be between 30% and 50% of predicted value and the patient may present with chronic symptoms. In very severe stage FEV1 is less than 30% of predicted value, except in some cases where it is found to be less than 50% but very severe chronic symptoms are observed in both cases. Although these stages are very useful for prognosis and treatment they cannot determine how long the patient is expected to live or to what extend the symptoms will affect the quality of life.

Prognosis is affected by many factors. Some people may live for months while others could live for years. However, life expectancy depends on patient’s age at the time of diagnosis and other health issues the patient may have, while lifestyle plays a major role. People with moderate to severe COPD usually have a lower life expectancy despite their age.

Exploring Challenges and Health Disparities Among Aging Asian Americans and Native Hawaiians and Other Pacific Islanders

Listening to the voices of native hawaiian elders and ‘ohana caregivers: discussions on aging, health, and care preferences. Browne and colleagues (2014) conducted a qualitative study that was involved in a larger 6 year mixed-method study carried out by Hā Kūpuna. The authors’ purpose for this study was to gain a clear understanding of social and health disparities among nā kūpuna (elderly).

Six focus groups were interviewed, each of which were recruited from community-based programs in rural islands of the state which include Hawaiʻi, Molokaʻi and Kauaʻi. Researchers stressed the importance for understanding cultural outlooks, values, and beliefs affecting the health and well being of Native Hawaiian kupuna.

The article is relevant to my research topic because it dives into the lived experiences of Native Hawaiians and explains the importance of community-based programs and its impact on aging in Hawaii for both elders and caregivers. This study is useful for analysing programs and interventions and addressing health disparities among Native Hawaiian elders. Best-practice physical activity programs for older adults: findings from the national impact study.

Hughes and colleagues (2009) evaluated existing physical activity programs for older adults. Specifically, they conducted a randomized trial to assess the impact of a multiple-component physical activity program for older adults. The programs were offered in community settings where they could target older adult participants. The authors focused on exercise adherence self-efficacy among the participants in the program.

Hughes and colleagues provided strong evidence that community providers can provide a multiple-component physical activity program that provides measurable benefits and outcomes of participant progress. Researchers measured participant progress in physical strength and consistent exercise participation. This study showed the importance that physical activity programs have on adults and why U.S. public policies should encourage these types of health promotion programs, being that they are inexpensive and effective at improving the quality of health among older adults.

This empirical study is useful in supporting the effectiveness and success of community-based program intervention for elderly populations.  Kaʻopua, L. S., Braun, K. L., Browne, C. V., Mokuau, N., & Park, C.-B. (2011). Why Are Native Hawaiians Underrepresented in Hawaii’s Older Adult Population? Exploring Social and Behavioral Factors of Longevity. Journal of Aging Research, 1-8. https://doi:10.4061/2011/701232

Kaʻopua and colleagues (2011) describes the influences of the health and longevity of Native Hawaiian elders. The authors explored the causes for premature mortality among the aging population in Hawaii and identified different ways on how sociodemographics and behavior factors vary by ethnicity among Hawaiiʻs aging population. Ethnicities involved in data collection included Native Hawaiian, Caucasian, Filipino and Japanese people, all ages 60 and older.

In order to explain the ethnic differences in life expectancy among these individuals, Kaʻopua and colleagues highlighted the differences in cause of death, health and behavior indicators. Findings compared Native Hawaiian elders with other major ethnic groups in Hawaii which displayed that Native Hawaiian elderly have the highest prevalence of chronic diseases such as asthma and diabetes. Along with chronic diseases, heart disease seemed to be the leading cause of premature death, resulting in loss of years of life. Results were consistent with prior research on the Hawaiian population documenting health and social disparities they face.

Kanti and Falconier (2017) conducted a qualitative study examining the experience of second generation Asian Americans who provide housing and financial support for first generation parents. Semi-structured interviews collected responses from individuals stating their responsibility for care giving out of love and not obligation. American and Asian cultural values are completely different in the way they view elder care. Asian views typically shift the responsibility of care to children, meaning they are expected to take care of their parents as they age. Kanti and Falconier point out how Asian adults are more likely to live with their elderly parents and financially support them due to cultural expectation.

Findings indicated that the majority of participants reported positive impacts, yet they all agreed caring for their parents limited their independence. Overall, the study identified challenges among Asian Americans due to a mix of asian cultural values transmitted by parents, combined with the cultural values of the individualistic society Lee, J. H., Heo, N., Lu, J., & Portman, T. A. A. (2013). Qualitative exploration of acculturation and life-p issues of elderly asian americans. Adultp Journal, 12(1), 4–23. https://doi: 10.1002/j.2161-0029.2013.00012.

This qualitative research study explored the life-p process of elderly Asian Americans. Lee and colleagues (2013) explored the cultural identity, social relationships and perceptions of aging among Asian American individuals.the results of the study provided insightful information that has implications for the counseling profession… The authors acknowledge how Confucian values influenced the views of a family oriented asian american lifestyle……. Moreover, the acculturation process that Asian Americans experience……

Maskarinec, G. G., Look, M., Tolentino, K., Trask-Batti, M., Seto, T., de Silva, M., & Kaholokula, J. K. (2015). Patient perspectives on the hula empowering lifestyle adaptation study: benefits of dancing hula for cardiac rehabilitation. Health Promotion Practice, 16(1), 109–114. https://doi.org/10.1177/1524839914527451

In this article, Maskarinec and colleagues (2015) describes the benefits of hulan as dance therapy and how it benefits individuals going through cardiac rehabilitation.patients enrolled were between 50-81 years of age.Ethnicity was not limited to pacific islanders but also included asain americans.Hula is a safe activity, also considered a dance therapy, that improved the functional capacity of the participants. The authors stress how a culturally effective cardiac rehabilitation program promotes integrated wellness and enduring cultural values… culturally resonant interventions have a much stronger impact than traditional forms of CR. Challenges and promises of health equity for native hawaiians. National Academy of Medicine, https://doi: 10.31478/201610d

This article describes the challenges Native Hawaiians face when it comes to health equity. Mokuau and colleage (2016) identify health and social disparities among native hawaiians while presenting programs that promise health equity for this population. Historical trauma caused by the United States is what caused health disparities among NH because of discrimmination and oppression…..

Nguyen D. (2010). Physician contact by older Asian Americans: the effects of perceived mental health need. Clinical interventions in aging, 5, 333–336. https://doi.org/10.2147/CIA.S14273
In this article, Nguyen (2010) examines the perception of mental health needs in older Asian American adults. The author associated the perception of mental health needs with a decreased number of physician contacts for Filipino and Korean Americans.

This study reveals the interethnic differences among older Asian Americans and their experience with contacting physicians. Nguyen stresses how crucial it is to correctly identify mental health needs of older Asian Americans in the healthcare system. This study encourages mental health professionals to work on reducing mental health disparities among older AA, designing culturally appropriate evidence-based interventions. This study contributes to the contribution of the identification and treatment of mental health concerns that need to be adapted/tailored to meet the needs of specific groups.

By tailoring intervention efforts to the help-seeking patterns of Asian American groups, mental health professionals can work toward reducing mental health disparities
Nishita, C., & Browne, C. (2013). Advancing Research in Transitional Care: Challenges of Culture, Language and Health Literacy in Asian American and Native Hawaiian Elders. Journal of Health Care for the Poor and Underserved 24(1), 404-418.

This peer-reviewed article describes a conceptual framework and proposes a research agenda that assess family health literacy ability, explores relationships between culture, decision making, and the development and adaptation of planning tools. Nishita and Browne (2013) examined the cultural values of the four major ethinic groups in Hawaii which include Chinese, Filipino, Japanese and Native Hawaiian older adults. Moreover, with Hawaii having a high percentage of Asain American (AA) and Native Hawaiians and Other Pacific Islanders (NHOPI) as a whole in the U.S, the authors identified the additional demands that multicultural adults will need in the future.

This article is useful for addressing the expectations for caregiving at home by extended family. The authors indicated how each ethnicity is unique in the way they define health , healthcare needs, health problems, healing illnesses and managing disabilities. Overall, findings show the intersectionality that cultural values have on an individuals health profile and itʻs influence for settings and delivery of long term care for the aging AA and NHOPI population in Hawaii Nishita, C. M., Hayashida, C., & Kim, E. (2014). Better care for complex, challenging clients: hawaii’s training program to improve residential long-term care.

This empirical study describes an innovative program to train caregivers and improve the skills of home and foster care facilities in Hawaii. The program is called the Kupuna Adult Care Home Project, which uses culturally relevant training modules that incorporates a combination of practical knowledge and active learning strategies to help participants work through real-life scenarios.The authors evaluated a total of 787 participants by measures of improved knowledge and satisfaction of the training.

Nashita and colleagues (2014) stress the importance of continuous education and training for personal and home care aids to improve quality and satisfaction of care for elderly patients. Findings from this program indicated high levels of satisfaction and gained knowledge. The limitation of this study is due to the access of the training program one one island, Oahu. For improvements, the authors recommend testing an online format to make the training modules more accessible to neighboring islands in the state of Hawaii, thus allowing caregivers to take the training classes at their convenience and at a reasonable price to sustain the program.

Reflection: Relevance to Topic: At the end, reflect and explain how all these articles are relevant to your research question and why it is important and how it expresses intersectionality
The purpose of my research is to examine the intersectionality of age and ethnicity among Asian Americans (AA) and Native Hawaiians and Other Pacific Islanders (NHOPI) populations in the state of Hawaii. Using an intersectionality lens, I wanted to examine the difficulties and challenges that arise among the aging population in Hawaii. Hawaii is a mixing pot of Polynesian and Asian ethinic groups with a rich cultural background. With such a diverse community comes differences for individual life experiences.

Hawaii is a multi-cultural place, which is why I chose to examine the impacts that intersectionality has as the community I grew up in ages.

Some articles are mainly focused on asian americans, while others are focused in native hawaiians and other pacfic islanders. I chose to break down my target population separately when looking into research articles because it allowed me to see the differences these populations face. Being that I focused on aging in Hawaii, it was important to break apart asians and polynesians as I found research articles, and allow them to collectively intersect to bring upon the broader issues of aging in Hawaii with the intersectionality of ethnicity, age and cultural backgrounds.
The 10 scholarly articles that I have selected embodies the intersectionality that the aging asian and pacific islander population encounters.

A few are specifically targeted at strictly Asian Americans, while ## articles focus on Native Hawaiians and other major ethnic groups which include filipino, chinese and japanese. For the six empirical articles I examined, I decided to focus on the importance of community based programs to gain a better understanding of the effectiveness and ability to be tailored to fit the specific needs of this diverse population. Physical activity programs were also a trend, and a reasonable one to assist and influence the aging population to be more physically active to maintain their health.

The National Association of County & City Health Officials (NACCHO), has assigned ten essential services to guide local health departments on what programs they should be offering to meet the needs of the people living in their communities.

To adhere to the second essential standard of “Protecting people from health problems and health hazards,” Michigan partners up with other government agencies such as the Center for Disease Control (CDC) to conduct its Medical Monitoring Project (MMP) (Michigan Department of Human Services [MDHHS], n.d.; NACCHO, 2005). This public health driven program is designed to provide awareness to what life is like living with HIV/AIDS by examining health records and interactive data locally and nationally.

With careful observation, researches can determine how many people with HIV are receiving medical attention, how accessible is their care, are their needs satisfied, and lastly, how is their treatment regimen affecting their lives? The data collected by MMP provides understanding to what health disparities this population faces and shares it with medical providers, other preventative groups, and policy leaders to lobby for the adequate resources to provide change.

The seventh standard “Help people receive health services” is an example of Michigan’s Diabetes Self-Management Education and Support (DSMES) service (NACCHO, 2005). This service establishes a system of personal health and preventative care to its residents. According to Michigan.gov (2019), “About 1 million Michigan adults have diabetes, and another 2.6 million have prediabetes.”

These numbers are a cause for concern because those who have prediabetes can easily fall into the category of a true diabetic if certain preventative measures are not taken. This service focuses on implementing strategies to support those living with diabetes and teach these patients how to manage the disease to ensure a better quality of life. An ideal candidate for this program is an individual who has been recently diagnosed with diabetes, a patient getting acquainted with a new medical team, or someone who has never had a comprehensive diabetes plan explained to them, or someone due for their annual diabetes education review.

Admittance to this program involves a referral from a medical provider and this service may not be covered under one’s insurance despite qualifying under all eligible categories. By meeting with trained healthcare providers, this service describes how patients are properly referred to other medical providers to tailor a health program suited to their specific needs. The strategies put in place by this local health program ensure Michigan residents are receiving accessible, preventative, and personal care.
The sixth standard” Enforce public health laws and regulations” demonstrates Michigan’s Drug take Back Day (NACCHO, 2005). Each year the Drug Enforcement Agency (DEA) declares national

Drug Take Back Days in which you can dispose of your residual prescription drugs to a specific site or “authorized collector” in your community (Drug Enforcement Administration [DEA], n.d.). An authorized collector could be a site such as pharmacy, clinic, or hospital that is lawfully registered through the DEA to gather unused pharmaceuticals for the purpose of destruction (DEA, n.d.). The DEA (2018), emphasized, that they have attained “4982 tons” of unused prescription drugs since 2010.

I assume most people are unaware that there is a proper way to dispose of prescription drugs and that there is a “Disposal Act” to ensure that unused pharmaceuticals are disposed in a manner that does not pollute the environment such as flushing pills down the toilet or just carelessly throwing tablets away in the trash. Michigan’s participation in this program enforces the essential service of protecting the public and the environment while complying with DEA regulations. These types of programs educate the public on the importance of not letting these lethal drugs get into the wrong hands as sadly the United States is in the “worst drug crisis in American history” (DEA.gov, 2018).

References

• Drug Enforcemwnt Administration. (2018). DEA brings in record number of unused pills during 15th annual national prescription drug take back day. Retrieved from
  https://www.dea.gov/press-releases/2018/05/07/dea-brings-record-number-unused-pills-during-15th-annual-national
• Drug Enforcement Administration. (2018). Disposal act: General public fact sheet. Retrieved from https://www.deadiversion.usdoj.gov/drug_disposal/fact_sheets/disposal_public_06222018.pdf
• Drug Enforcement Administration. (n.d.). Disposal regulations: Registrant fact sheet. Retrieved from https://www.deadiversion.usdoj.gov/drug_disposal/fact_sheets/disposal_registrant.pdf
• Michigan Department of Health and Human Services. (2019). Diabetes. Retrieved June 17, 2019, from https://www.michigan.gov/mdhhs/0,5885,7-339-71550_63445_82468—,00.html
• Michigan Department of Health and Human Services. (n.d.). HIV/AIDS medical monitoring project. Retrieved June 14, 2019, from https://www.michigan.gov/mdhhs/0,5885,7-339-71550_2955_2982_46000_46002-165550–,00.html
• National Association of County & City Health Officials. (2005). Operational definition of a functional local health department. Retrieved from https://www.naccho.org/uploads/downloadable-resources/Operational-Definition-of-a-Functional-Local-Health-Department.pdf
• Public Health for Michigan for You. (2011). Local liaison report to local health departments. https://s3.us-east-1.amazonaws.com/blackboard.learn.xythos.prod/5910dce636852/20805?response-content-disposition=inline%3B%20filename%2A%3DUTF-8%27%27January_07_LLR_184863_7.pdf&response-content-type=application%2Fpdf&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-
• Date=20190614T230554Z&X-Amz-SignedHeaders=host&X-Amz-Expires=21599&X-Amz-Credential=AKIAIL7WQYDOOHAZJGWQ%2F20190614%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Signature=ea0a8a247acf61e0e5fc88ca0356ccb8ad84e807cd53e23e247b5ac08a454677

A genogram is used to bring a deep insight of family background that helps counselors to map out family relationships and traits enhancing their knowledge about the family. This tool was developed by Monica McGoldrick and Randy Gerson and is commonly used in clinical settings to diagnose and treat substance use disorders (Metcalf, 2019).

Common features of the genogram include the number of families, number of children in a specific family, birth order, and number of deaths within the families. The genogram provides family information across several generations. Other information provided by the genogram includes the medical history, common behaviors, patterns of family history, and problems within the family (Metcalf, 2019). This project will examine my own family history from a counseling perspective using the genogram.

Genogram

Significant Issues Identified

Based on the genogram, my grandfather (Stephen) had health problems that may have contributed to alcoholism. He had cancer and diabetes that are illness which may emotionally and mentally affect a person leading to alcoholism or substance abuse.

This is because these diseases have no cure and affected individuals undergo through discouraging times (Plant & Holland, 2018). Without adequate support from family members, affected individuals may be entangled in drug use. My grandfather lost his job where he worked for the aviation industry. He later became a farmer where he would get lump sum payments for goods delivered in retail stores. This contributed to his alcoholic behavior where he would sleep out in drinking sprees (Plant & Holland, 2018). This led to a strained relationship with his wife (Jane) where violence was also witnessed.

Stephen felt that his family was not supportive to him through the difficulty times. On the other hand, his wife had high blood pressure and suffered depression due to this disease as well as the violence from his husband. Stephen was also hostile to his three children Daniel, Joyce, and Alex. However, their grandmother loved and cared for her children protecting them from their father (Plant & Holland, 2018).

Their children have a hateful relationship with one another that may be attributed to the violent environment. Daniel, who is my father married Ruth (my mother) and have two children Donald (me) and my sister Beatrice. Their relationship is however full of distrust that may be attributed to the strained relationship between my father and his father. Alcoholism is also common in my family that has further affected the relationship between my father and mother (Plant & Holland, 2018).

My father is also suffering from diabetes and experiences extreme moods. However, we are best friends and shares personal experiences with me. This may be attributed to the reason that I am his only son and our relationship is cordial (Godleski & Leonard, 2019). He has continuously expressed how his father disappointed him in various ways and did not support him in achieving life goals.

This has led to him making certain provisions and providing support to me to ensure that I will achieve my goals in life. One of the positive attributes regarding my family that has influenced me in various perspectives is the Christian background (Godleski & Leonard, 2019). This is based on the belief of a one true sovereign God who has power over all the creation.

Most of my decisions are based on godly values and even though some members may participate in some activities that are considered immoral, there is a desire to change the negative behaviors due to the consequences on the person as well as other members of the family (Guttmannova et al., 2017). My relationship with my mother has been a good one and she has guided me in most of life’s transitions.

One of the expectations of men in my family is to provide and protect the family. This has been the responsibility of my grandfather as well as my father. However, when my grandfather lost his job in the aviation sector, he became a farmer a process that saw his income decline rapidly (Guttmannova et al., 2017). This was worsened by the reason that his family expected him to continue providing for the family.

Since my father is unemployed, this has negatively affected his status as the leader of the house and feels that he does not deserve to become a father. However, he has supported his family with whatever he gets from some of the personal businesses that he carries out occasionally (Godleski & Leonard, 2019). One unique family history that has influenced my personal identity is the loss of a job for my grandfather.

This has positively influenced me in choosing my career as well as making important life’s decisions. My grandfather’s alcoholic behavior led to a strained relationship within his family an aspect that is similar with his son’s family (Godleski & Leonard, 2019). This is evident where some of the issues that were experienced in my grandfather’s family are being experienced in my father’s family.

Conclusion

Using a genogram, counselors can identify intergenerational family patterns or themes that influence current families. Family history is also provided that indicates some of the issues that may likely arise in the future (Gerhardt, 2019).

In diagnosing substance use disorders, this information is important since it enables counselors to make accurate diagnosis and select effective treatment interventions for the clients. This is because the counselor understands the emotional, spiritual, and biological relationship between different family members which will help in breaking generational issues that have negatively affected families due to the problems associated with the issues (Gerhardt, 2019).

References

• Gerhardt, C. E. (2019). Families in Motion: Dynamics in Diverse Contexts (1st Edition). Los Angeles. SAGE Publications.
• Godleski, S., & Leonard, K. E. (2019). Substance use and substance problems in families: How families impact and are impacted by substance use. APA handbook of contemporary family psychology: Applications and broad impact of family Psychology. Vol. 2. (pp. 587–602). American Psychological Association. https://doi-org.lopes.idm.oclc.org/10.1037/0000100-036
• Guttmannova, K., Hill, K. G., Bailey, J. A., Hartigan, L., Small, C. M., & Hawkins, J. D. (2017). Parental Alcohol Use, Parenting, and Child On-Time Development. Infant and Child
• Development, 26(5), e2013. https://doi.org/10.1002/icd.2013
• Metcalf, L. (2019). Marriage and family therapy: A practice-oriented approach. New York, NY: Springer Publishing Company, LLC.
• Plant, C. P., & Holland, J. M. (2018). Family Behavior Therapy for Alcohol and Drug Problems in Later-Life. Clinical Gerontologist, 41(5), 508–515. https://doi.org/10.1080/07317115.2017.1349701

So far, nearly 100 million animals have been used for experiments annually. Many people have been arguing whether animal testing be banned? Obviously, the answer is animal testing should not be banned. Due to animal can be tested to ensure the safety of some cosmetics, animal testing has contributed to many life-saving and treatment and animal testing has also benefited on animal themselves, so animal testing has become an indispensable part of human development.

To begin with, animal can be tested in order to ensure the safety of some cosmetics. Personal care products will be used an average of 12 in American woman, and animal testing can better protect humans from cosmetic damage before they use cosmetics. According to American Food and Drug in the article (2017), animal testing definitely should be used in cosmetics because animal testing can ensure the safety of products or ingredients. For example, sunscreens and anti-dandruff shampoos include some chemical compositions that cause chemical changes that maybe harmful to human’s body. Human use these untested cosmetics and base on the average daily use of cosmetics in the United States, the security of ourselves will be riskier. Therefore, the safety of cosmetics cannot without animal testing.

Furthermore, animal testing has contributed to save our lives. Every life is very precious, and no one wants to leave this beautiful world because of illness. Dr.Chris in animal research (2013) states that “we wouldn’t have a vaccine for hepatitis C without chimpanzees,” Hepatitis C is a disease that thousands of American were killed annually. Animal testing is an important way of solving disease problems. Simon in the article (2008) says some medicine has already applied, such as antibiotics, anesthetic, organ transplants, and diabetes insulin are all breakthroughs in animal testing. These results have successfully saved millions of humans around the world. Animal testing has become an indispensable part of saving lives. Therefore, this is why animal testing has contributed a lot to save our lives.

In addition, animal testing has also benefited on animal themselves. Dogs are one of our most loyal partners and no one wants them to suffer illness. According to American Food and Drug in the article (2016), a drug from animal testing helps 80% of dogs with lymphoma. The Foundation for Biomedical Research’s animal research campaign in the Brochure (2017) also states that animal testing has improved and saved the lives of pets. These contributions are good for the animals to solve the disease. For example, rabies, infectious hepatitis and tetanus of animals can be solved by drugs with animal testing. So, animal testing also helps animal to benefit themselves.