Medicine and Health Sciences Commons^™

Efficacy Of Observational Care Versus Antibiotic Therapy For Treatment Of Acute Uncomplicated Diverticulitis, Morgan Mooty, Abbie R. Bauer

Clinical Research in Practice: The Journal of Team Hippocrates

A clinical decision report using:

van Dijk ST, Daniels L, Ünlü Ç, et al. Long-Term Effects of Omitting Antibiotics in Uncomplicated Acute Diverticulitis. Am J Gastroenterol. 2018;113(7):1045-1052. https://doi.org/10.1038/s41395-018-0030-y

for a patient with acute uncomplicated diverticulitis.

Ultrasound – An Underutilized Diagnostic Tool For Ventricular Assist Device Driveline Infections, Kristina Krzelj, Tomislav Tokic, Tomislav Kopjar, Maja Cikes, Davor Milicic, Hrvoje Gasparovic

The VAD Journal

Patients with ventricular assist device (VAD) driveline infections (DLI) have reduced quality of life and increased risk of severe complications, such as sepsis, hemorrhagic or ischemic stroke, and wound infections. The management of VAD patients imposes a significant financial burden due to prolonged in-hospital stays, frequent re-admissions, expensive diagnostics, and the need for antibiotic therapy and/or surgical intervention. There is considerable room for improvement in DLI management, particularly in the early detection and treatment stages. Ultrasound, an easily applicable device available in almost every hospital, offers an unrecognized potential for the early detection of DLI. By increasing awareness about the …

Comprehensive Comparison Of Clinicoradiological, Laboratory, And Prognostic Factors Of Community-Acquired Pneumonia In Diabetic And Nondiabetic Hospitalized Patients, Seyyed Hamid Hashemi, Fatemeh Saki, Shiva Borzouei, Rashed Bawand, Alireza Soltanian

Turkish Journal of Medical Sciences

Background/aim: Community-acquired pneumonia (CAP) is one of the leading infectious causes of mortality, and diabetes mellitus is a globally prevalent disease. Consequently, the cooccurrence of these two disorders can be common and create challenging medical conditions. Therefore, it was aimed to compare the various aspects of CAP in diabetic and nondiabetic patients, in order to have a comprehensive and comparative picture of the differences. Materials and methods: In this cross-sectional study, CAP patients with and without diabetes were assessed for clinicoradiological signs, laboratory features, disease severity, and pneumonia outcomes. Results: Analyzed herein were 172 CAP patients (77 had diabetes and …

The Diagnostic Profile And Clinical Course Of Patients With Rheumatic Diseases In The Medical Intensive Care Unit, Kani̇ye Aydin, İpek Türk

Turkish Journal of Medical Sciences

Background/aim: Immunosuppressive and immunomodulatory treatments developed in recent years as a result of a better understanding of the pathophysiology of systemic rheumatic diseases (SRDs) improve the prognosis. Despite medical advances, individuals with SRDs at any stage may require intensive care and have a high mortality rate. The aim of this study was to investigate the demographic and clinical characteristics of patients with rheumatic diseases admitted to the intensive care unit (ICU), and the factors associated with the risk of mortality. Materials and methods: This was a retrospective, cross-sectional study that included patients with rheumatic diseases in the medical ICU. Factors …

Clinical Utility Of Neutrophil To Lymphocyte Ratio In Sickle Cell Disease With Vaso-Occlusive Crisis, Satish Maharaj, Simone Chang

Hematology/Oncology and Stem Cell Therapy

Background and objectives: The neutrophil-to-lymphocyte ratio represents a universally accessible value that correlates with inflammation and prognosis in several disease states; however, the role of this biomarker in sickle cell disease remains poorly explored. Hence, the objective of the present study was to determine its potential clinical utility in patients with sickle cell disease.

Patients: Herein, we retrospectively reviewed 143 patients with sickle cell disease who presented to the emergency department with fever and painful vaso-occlusive crisis.

Results: The examined cohort had a prevalence of 11% confirmed bacterial infection, with approximately two-thirds reporting the use of hydroxyurea. The neutrophil-to-lymphocyte ratio …

Evaluation Of Resistant Associated Variants / Substitutions (Ravs/Rass) Role In Management Of Compensated Naive And Experienced Chronic Hepatitis C Virus Infection, Gamal Mohammad Mohammad Soliman, Ashraf Taha Abd Elmouttaleb, Mostafa Abd Elaziz Ahmed Abd Elrahman, Mohamed Ghareb Mohamed Shikhroho, Amr Mohammed Mohsen Aly Badary

Al-Azhar International Medical Journal

Background: The success of DAA-based combination therapy for the treatment of HCV NS3 resistance-associated substitutions (RAS) is influenced by their occurrence. Objective: The main aim of this study were; 1) identifying the association of HCV relapse (post treatment with ani-NS5A DAAs Simeprevir or Daclatasvir) with occurrence of RAVs/RASs (Resistance associated substitutions) of nucleotide and specific amino acid replacement among Egyptian. Methods: This cross-sectional, case-control study was conducted. Patients were enlisted by Tropical Medicine. Department outpatient clinics at El-Hussein University (Al Azhar University Faculty of Medicine) and EL-Agouza Police hospital. 150 HCV patients in all were involved in the study.These three …

Retrospective Analysis Of Risk Factors And Management Of Infection After Lumbar Spine Implantation, Hussien Mohamed Mohamed, Hussein Abo El-Gheit, Mohamed Abulsoud

Al-Azhar International Medical Journal

Background: Wound infection still has a negative impact on patient outcomes after spine surgery, despite the discovery of preventative medicines as well as improvements in surgical approach and postoperative care. The risk of intraoperative/postoperative infection is increased by utilizing a posterior surgical approach, applying instrumentation, using an allograft, requiring a blood transfusion, and longer operations.

Aim of the study: To determine the prevalence and risk factors for post-operative instrumental lumbar spinal infection and evaluate functional outcomes after the management of the infections.

Patients and Methods: This study was conducted on diseased persons whom had an infection after lumbar spine instrumentation …

Update In Laboratory Diagnosis Of Urinary Tract Infection, Weny Rinawati, Diana Aulia

Jurnal Penyakit Dalam Indonesia

Urinary tract infection (UTI) is an infection caused by the entry of pathogens into the urinary tract. Symptoms of a UTI are not always obvious, and some are asymptomatic or atypical. Urinary tract infections must be distinguished from other diseases that have a similar clinical appearance. Many UTIs resolve spontaneously, but often cause significant morbidity and mortality. With the unpredictable nature of the disease, laboratory tests are required for accurate diagnosis and identification of the cause of infection. Thus, it is necessary to understand the interpretation and limitations of urinalysis and urine culture results. To assist in the diagnosis of …

Laboratory Findings In Covid-19 - Alterations Of Hematological, Immunological, Biochemical, Hormonal And Other Lab Panels: A Narrative Review, Yousef Rasmi, Lucas Paulo Jacinto Saavedra, Matei-Alexandru Cozma, Heba El-Nashar, Shaza Aly, Nouran Fahmy, Omayma Eldahshan, Mohamed El-Shazly, Elena Codruța Dobrică, Hamed Kord-Varkaneh, Camelia Cristina Diaconu, Mihnea Alexandru Găman

Journal of Mind and Medical Sciences

Up to the present date, according to the official reports of the World Health Organization (WHO), 205,338,159 patients have been confirmed with the coronavirus disease (COVID-19) and 4,333,094 have died as a consequence of this infectious disorder. The majority of COVID-19 patients will develop hematological, biochemical, immunological, hormonal and other complex alterations of their laboratory data which may be diagnosed using different biomarkers. In this paper, we review the alterations of the hematology, immunology, biochemistry, hormonal and other laboratory panels discovered in the subjects diagnosed with SARS-CoV-2 infection, based on the available data in the literature.

Identification Of Subclinical Iron Deficiency Using New Erythrocytes, Leukocytes, And Reticulocytes Parameters During Nonsevere Acute Infection In Pediatric Outpatients, Nazmi̇ Mutlu Karakaş, Serap Ki̇rki̇z Kayali, Zühre Kaya

Turkish Journal of Medical Sciences

Background/aim: This study aims to investigate the diagnostic utility of new erythrocytes, leukocytes, and reticulocytes parameters for the identification of subclinical iron deficiency (ID) in children under 6 years with nonsevere acute infection in pediatric outpatients. Materials and methods: The study included 102 children with acute infections and 31 true ID. Traditional and new hematology parameters were measured in a Sysmex-XN® , along with C-reactive protein level, and iron parameters. Participants? ID were categorized as: the ferritin < 100 ng/mL, transferrin saturation < 20% was defined as ?subclinical or functional ID (FID) in Group 1?; ferritin < 30 ng/mL, transferrin saturation < 20%, as ?absolute-ID (AID)? in Group 2; ferritin < 12 ng/mL without anemia and infection, as ?true ID? in Group 3. Results: The frequencies of FID and AID among the 102 children with acute infection were 24% and 76%, respectively. Compared with the Group 2 patients, Group 1 had a significantly higher mean percentage of hypochromic erythrocytes (Hypo-He), and significantly lower levels of hemoglobin (Hb) and Hb content of reticulocytes (RET-He) (p < 0.05 for all). Compared with Group 2 and Group 3 patients, Group 1 had a significantly higher mean percentage of immature reticulocyte fraction (IRF) and immature granulocyte (IG) values (p < 0.05 for all). The RET-He, IRF%, Hypo-He%, and IG% cut-off values for predicting FID during infection were 27.0 pg, 10.6%, 2.5%, and 0.35% respectively. Conclusion: The RET-He, Hypo-He, IRF, and IG may be useful parameters for identifying subclinical ID in small children with nonsevere acute infection in pediatric outpatients.

Topical Formulations Based On Polyhexamethylene Hydrochloride Guanidine For Surgicalfield Antisepsis, Fernanda Gosuen Gonçalves Dias, Renato Luis Tame Parreira, Lucas De Freitas Pereira, Rodrigo Cássio Sola Veneziani, Maria Anita Lemos Vasconcelos Ambrósio, Vinícius Thomaz Da Silva Almeida, Renata Alves De Barros, Luis Gustavo Gosuen Gonçalves Dias, Sérgio Ricardo Ambrósio

Turkish Journal of Veterinary & Animal Sciences

As surgical site infection can prolong the patient's hospital stay, increase morbidity and mortality rates and medical and hospital expenses, justifying the search for new effective and low-cost antiseptic drugs is justifiable. Thus, the objective of the present study was to analyze, by direct clinical and microbiological examination, the topical antiseptic effect of a solution based on polyhexamethylene hydrochloride guanidine (PHMGH) at 0.5% on the intact skin surface of sheep and cats, aiming at its use in operative field (previous and definitive antisepsis), compared to 0.5% alcoholic chlorhexidine and association with this. The topical solutions did not cause any skin …

Prevalence Of Esbl-Producing Enterobacteriaceae Among Lebanese Patients With Urinary Tract Infections, Rasha Abdallah, Bassel Abdallah

BAU Journal - Health and Wellbeing

Being the most common infections worldwide, Urinary Tract Infections (UTIs) represent a major public health problem. Gram negative bacteria are the main pathogens causing UTIs where Extended spectrum β–lactamase (ESBL)-Producing Enterobacteriaceae, mainly the multi-drug resistant species, such as E. coli sequence type 131 and klebsiella.pneumoniae, account for serious health problems and high economic burden. In Lebanon, data about prevalence of antibiotic resistant pathogens during UTIs are still scarce. In this study we examined the prevalence of ESBL-producing pathogens among Lebanese patients mainly located at Bekaa governorate. This retrospective study included 7241 urine tests that were collected from all the …

Assessment Of Nurses’ Knowledge And Care Practices For Infection Prevention In Neutropenic Patients In Bekaa, Lebanon: A Descriptive Cross-Sectional Design, Mona Mortada, Salim Moussa

BAU Journal - Health and Wellbeing

Neutropenia is one of the serious complications to chemotherapy that increases the risk of infection and even mortality. Nurses’ knowledge about neutropenia and their care practices are essential in order to protect neutropenic patients from infection. Thus, this study aimed to assess nurses' knowledge and care practices for infection prevention in neutropenic patients in Bekaa, Lebanon. A cross-sectional descriptive research study had been conducted in five hospitals located in Bekaa district. 81 nurses had been recruited by convenience sampling. They completed the ‘Nurses’ Knowledge and Care Practices for Infection Control in Neutropenic Patients’ questionnaire. The majority were females 77.8% (n=63), …

Variations In Covid-19 Airway Management And Preparedness Among Victorian Hospitals, Kaylee A. Jordan, Teresa M. Sindoni, Reny Segal, Keat Lee, Roni B. Krieser, Paul Mezzavia, Yinwei Chen, Irene Ng

Journal of Perioperative Nursing

The COVID-19 pandemic presents significant concerns surrounding the risk of transmission to health care workers involved in airway management of patients with suspected or known infection. Limited evidence has been available to guide the preparation of staff, intubation environments, team structure and personal protective equipment. Our study invited Victorian hospitals to complete a survey on their airway management practices and protocols, in order to assess the degree of variability in practice and preparedness. Twenty hospitals responded in September 2020, during Victoria’s second wave of COVID-19. Forty percent had dedicated COVID-19 intubation teams, all including consultant anaesthetists. Seventy-five percent had negatively …

Multiple Noncontiguous Spondylodiscitis Following Mastectomy Secondary To Breast Carcinoma: Case Report And Literature Review, Ghazwan Hasan, Ali Ali, Ameer Al-Jasim, Shahbaz Khan

Advanced Spine Journal

Background Data: Multiple noncontiguous spontaneous pyogenic spondylodiscitis is rare and has only been explained in the literature by case reports and case series. Purpose: We present a case report of multiple noncontiguous spontaneous spondylodiscitis caused by E. coli involving the cervical and lumbar spine following a mastectomy for breast cancer. We will explain the difficulties in diagnosis, treatment, and follow-up with the concomitant. Study Design: A case report and literature review. Case Report: A middle-aged patient with a history of breast carcinoma underwent surgery. Two weeks after mastectomy, the patient developed severe cervical and lumbar spine pain and a low-grade …

Prion Disease: A Challenging Diagnosis, Jeffrey F. Spindel, Anita M. Fletcher, William T. Smith, Rodrigo Cavallazzi

The University of Louisville Journal of Respiratory Infections

Introduction: Human prion diseases are a group of rare encephalopathies resulting in rapidly progressive dementia and ultimately death. While there are no effective treatments for any form of prion disease, prompt and efficient diagnosis is essential to prevent the spread of the self-propagating protein, which may occur through aerosols, and avoid unnecessary or invasive testing. Diagnosis relies largely on physical examination, with many nonspecific findings, and laboratory testing, which has wide ranges of reported accuracy and high false positive rates with diseases such as Alzheimer’s dementia.

Methods: Patients who underwent testing for prion disease were retrospectively identified from the electronic …

Streptococcus Anginosus Lung Infection And Empyema: A Case Report And Review Of The Literature, Nishita Tripathi, Kuldeep Ghosh, Anupama Raghuram

The University of Louisville Journal of Respiratory Infections

Streptococcus milleri group (SMG) also referred to as the Streptococcus anginosus group. These are Gram-positive, variable hemolysis, catalase negative, microaerophilic, non-motile facultative anaerobes which have been known to cause abscesses in humans. We report a case of empyema caused by Streptococcus anginosus in a patient with an unresolved pneumonia for over a month. In early October 2018, the patient presented to an emergency room with the complaints of shortness of air, productive cough, chills, subjective fever and weight loss for 4 weeks. A chest X-ray revealed a left lower lobe pneumonia. He was treated with 250 mg of azithromycin for …

Supply, Demand, And Quality: A Three-Pronged Approach To Blood Product Management In Developing Countries, Kyle L. Gress, Karina Charipova, Ivan Urits, Omar Viswanath, Alan D. Kaye

Journal of Patient-Centered Research and Reviews

While transfusion of blood and blood products is instinctively linked to the provision of emergent care, blood and blood products are also routinely used for the treatment of subacute and chronic conditions. Despite the efforts of the World Health Organization and others, developing countries are faced with a three-part problem when it comes to access to and delivery of transfusions: insufficient supply, excessive demand, and inadequate quality of available supply. Developing countries rely heavily on replacement and remunerated donors rather than voluntary nonremunerated donors due to concerns regarding donation- and transfusion-transmitted infection as well as local and cultural beliefs. While …

Management Of Primary Spondylodiscitis: Clinical Outcome Of A Series Of Twenty-Seven Patients, Mohamed Nagy, Mahmoud Wahdan, Ahmed Saleh

Advanced Spine Journal

Background Data: Spondylodiscitis is a major clinical condition with significant health and economic burden. There is a controversy regarding the use of conservative therapy with systemic antibiotics alone versus combined with surgery to manage primary spondylodiscitis. Study Design: Retrospective clinical case study. Purpose: To assess the clinical outcome of treatment of the patients with primary spondylodiscitis. Patients and Methods: This study was conducted on 27 patients with primary spondylodiscitis. There were 17 males and 10 females. The mean age was 49.96 ± 9.83 years. All the patients presented with local pain over the involved vertebral level. The clinical outcomes were …

Current Infection Prevention And Control Strategies Of Covid-19 In Hospitals, Gamze Kalin Ünüvar, Mehmet Doğanay, Emi̇ne Alp

Turkish Journal of Medical Sciences

Background/aim: Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has been appeared first in China since December 2019. Transmission of SARS-CoV-2 occurs primarily with droplets through coughing and sneezing and also occurs through inhalation of aerosolized secretions, which travel, remain suspended in the air longer. Materials and methods: Since early stages of the outbreak, COVID-19 cases have been described in healthcare workers (HCWs). However, in the early stages, the disease may be asymptomatic. This may lead to incorrect diagnosis or delayed diagnosis and may lead to the nosocomial spread of the virus. One of the …

Hyponatremia In Hospitalized Children With Bronchiolitis And Severe Bronchial Asthma, Maha A. Tawfiq, Manal A. Elsayed Yousef, Mohamed Mekawy, Soheir S. A. Elella

Menoufia Medical Journal

Objective The main objective is to study the frequency of hyponatremia in hospitalized children with bronchiolitis and severe bronchial asthma and its relation to severity of the disease. Background Hyponatremia is the most common electrolyte abnormality seen in hospitalized patients with lower respiratory tract infections such as bronchiolitis and bronchial asthma. Patients and methods This is a case–control study, involving 69 cases of bronchiolitis and 31 cases of severe bronchial asthma, conducted in Menoufia University Hospitals from November 2017 to April 2018. All cases were subjected to history taking, clinical assessment, and investigations, including complete blood count, C-reactive protein, serum …

The Absence Of Prophylactic Antibiotics Administration And The Surgical Site Infections Rate In Mohs Micrographic Surgery, Riva Ambardina Pradita, Larisa Paramitha Wibawa

Journal of General - Procedural Dermatology & Venereology Indonesia

Background: The use of prophylactic antibiotics in dermatologic surgery, particularly in Mohs micrographic surgery (MMS), remains a gray area. Despite the low rate of surgical site infection (SSI), SSI can result in some significant morbidities. Thus, numerous dermatologists keep administering prophylactic antibiotics in MMS.

Method: A search was conducted to identify clinically significant topics followed by literature review through the main available medical literature database. The three selected studies that met the inclusion and exclusion criteria were then critically assessed for their validity, importance, and applicability using the guidance from Centre for Evidence-Based Medicine for Critical Appraisal …

Depression Is Associated With Decreased Severity And Lower Mortality In Non-Elderly Hospitalized Adults With Influenza In The United States, Timothy L. Wiemken, Daniel Hoft, Jeffrey Scherrer

The University of Louisville Journal of Respiratory Infections

Background: Depression is associated with risk for chronic disease, though its relationship with infectious diseases is less understood. Depression may modify the clinical outcomes of patients with infectious diseases such as influenza via its association with inflammation. The objective of this study was to evaluate the relationships between depression and clinical outcomes in non-elderly adults with influenza infection.

Methods: This was a secondary analysis of the Nationwide Inpatient Sample database, years 2012–2016. Hospitalized adults aged 18–65 admitted during each influenza season were included. Depression status was documented via ICD-10 codes. The association between depression and clinical outcomes (e.g., …

Anterior Approach To The Thoracic And Thoracolumbar Spine: A Prospective Study In Our Hospital, Sarang Gotecha, Prashant Punia, Deepak Ranade, Anil Patil, Ashish Chugh, Megha Kotecha

Advanced Spine Journal

Background Data: Anterior approaches to the thoracic and thoracolumbar spine have several advantages including direct access to the lesion, less surgical bleeding, low risk of infection, and shorter segment fixation devices. It provides excellent visualization and access to the anterior thoracic spine, vertebral bodies, intervertebral disks, spinal canal, and nerve roots and may improve neurological outcome. Purpose: To evaluate various outcome parameters of the anterior approach to the thoracolumbar spine of various pathologies. Study Design: Prospective clinical case study. Patients and Methods: Thirty patients were included in this study. Patients with infections, malignancy, and trauma were included, while patients with …

Skin Diseases In Elderly, Al Zahraa A. Hasanin, Mohamed A. Gaber

Menoufia Medical Journal

Objective The present study aimed to determine the prevalence of the most common dermatological conditions in elderly patients and to investigate their associations with systemic diseases. Background Skin problems in the elderly population have rarely been the subject of scientific research. Patients and methods The study involved a group of 260 consecutive patients aged more than or equal to 60 years who were admitted to the Departments of Dermatology at the study institution. All participants were thoroughly evaluated in a clinical interview and physical examination in which special emphasis was placed on dermatological issues. Results All patients presented at least …

The Effect Of Educational Intervention On The Knowledge Of Nurses Regarding Catheter Indications And Catheter Associated Urinary Tract Infection Preventive Measures, Maryam Kbaysi, Esin Kavuran, Ahmad Tassi, Mirna Fawaz

BAU Journal - Health and Wellbeing

Catheter associated urinary tract infection (CAUTI) is the fourth leading cause of healthcare associated infections. The single most important predisposing factor for CAUTI is the insertion of urinary catheter. The aim of this study was to assess the effect of educational intervention on the knowledge of nurses regarding catheter indications and CAUTI preventive measures. A Pre-Post-test study design was utilized in this study which was conducted at two university hospitals one in Saida (South Lebanon) and the other one in Beirut in Lebanon. A self-reported questionnaire about catheter insertion and CAUTI prevention was used before and after the educational intervention, …

A Case Of Tetanus With Classical Presentations, Maaz Khan, Dr. Bhanukumar M

Digital Journal of Clinical Medicine

No abstract provided.

Pathogenicity Of Aerobic Bacteria Isolated From Honeybees (Apis Mellifera) In Ordu Province, Emi̇ne Şeyma Boğ, Ömer Ertürk, Mustafa Yaman

Turkish Journal of Veterinary & Animal Sciences

The honeybee (Apis mellifera) is an important pollinator insect. Any pathogenic infection in this beneficial insect is undesirable. In this study, bacterial diversity in beehives was investigated to determine the potential of pathogenic bacteria in honeybees. To do this, bacterial isolations were carried out from dead and diseased adult bees collected from 9 districts in Ordu Province in Turkey.Twenty species of pathogenic bacteria, 18 of which were nonsporeforming Staphylococcus lentus, Klebsiella oxytoca, Citrobacter freundii, Leucanostoc mesenteroides ssp. cremoris, Kocuria rosea, Kocuria kristinae, Sphingomonas paucimobilis slashline, Burkholderia cepacia, Leucanostoc mesenteroides ssp. dextranicum,Hafnia alvei, Escherichia coli, Aeromonas salmonicida, Citrobacter braakii, Pantoea agglomerans, …

Managing A Conflict-Related, Open Fracture With Drug-Resistant Infections: The Case Of A Wounded Syrian Refugee In The Hashemite Kingdom Of Jordan, Alex Green

Clinical Research in Practice: The Journal of Team Hippocrates

A critical appraisal and clinical application of Uruc V, Ozden R, Duman IG, Dogramaci Y, Yengil E, Karapinar S, Karakus A, Kalaci A. Major musculoskeletal injuries and applied treatments in the current conflicts in Syria. Acta Medica Mediterranea. 2014;30(3):637-644.

Infection Of Plasmodium Knowlesi Malaria In Human, I Gede Yasa Asmara

Jurnal Penyakit Dalam Indonesia

Plasmodium knowlesi (P. knowlesi) has been recognised as the fifth of malaria infections in human after P. vivax, P. falciparum, P. malariae and P. ovale. Epidemiology and clinical features of the disease have much been discussed only in several literatures since the incidence increased in Kapit Division, Sarawak, Malaysia in 2004. A large-scale research investigating real incidence of the infection in South East Asia is important. Because of rapid life cycle, the number of parasite in the blood can increase significantly, result in potential severe malaria. Pathophysiology aspect of the disease has not been clear yet, particularly on how severe …