Open Access Case Report

Miliary Tuberculosis with Cutaneous Affectations and SARS-CoV-2 Coinfection in Infant: Case Report in Mexico

Ivonne Juarez Reyes, Jose Alfredo Vidal Vidal, Virginia Lora Tellez, Ma. Fabiola Del Carmen Lara Hernandez, Magdalena Molina Macip, Alejandra Silva Hernandez, Patricia Daniela Gogeascoechea Guillen, Brenda Mariel Valerdi Zepeda, Angie Giovanna Velasco Peraza, Froylan Eduardo Hernandez Lara González

Journal of Advances in Medicine and Medical Research, Page 43-50
DOI: 10.9734/jammr/2022/v34i131247

Aims: To describe an infant presenting with miliary tuberculosis with cutaneous affectations and SARS-CoV-2 coinfection.

Presentation of Case: 10 month old boy, with incomplete vaccination. Low Socio-economic status. The parents indicated, that lesion began with a single small, erythematous, non-pruritic, papule-type skin lesion on the left side of the infralabial region, with no other constitutional. During the following three months, the lesions became generalized. On June 23, 2020, he was admitted to the “Hospital para el Niño Poblano” in emergency area with mild malnutrition, lethargic state, fluid and electrolyte imbalance, metabolic acidosis, oral candidiasis, and septic shock, requiring endotracheal intubation. Besides, innumerable acid fast bacilli in skin biopsy and bronchial aspirate with diagnosis cutaneous TB was, identified. Immunodeficiency based on immunoglobulin profile and T and B cell markers. RT-PCR was performed for SARS-CoV-2 in bronchial aspirate, with a positive result. On June 25, 2020 died of cardiorespiratory arrest, secondary to septic shock and cutaneous tuberculosis.

Discussion: Miliary TB in infants is difficult to diagnose in addition the cutaneous manifestation has added onto the long list of differentials, and downplay others, generating inappropriate and delayed treatment. Additionally, SARS-CoV-2 can intensify the clinical manifestations of miliary tuberculosis and directly influencing the mortality of this type of patients.

Conclusion: The case described is rare, which reveals the importance to perform a differentiated diagnosis, considering Socio-economic and epidemiological context mainly in the first level of care. It is recommended to continue with research in order to generate information on the possible clinical pictures.

Open Access Original Research Article

A Prospective Study on Clinical Efficacy of Intravitreal Bevacizumab and Macular Grid Laser in Patients with Macular Edema Secondary to Branch Retinal Vein Occlusion

Soumyadeep Hazra, Tapes Kanti Saha

Journal of Advances in Medicine and Medical Research, Page 1-9
DOI: 10.9734/jammr/2022/v34i131243

Background: Branch retinal vein occlusion (BRVO) is the second most common cause of retinal vascular abnormality after diabetic retinopathy. Persistent macular edema develops in 60% of eyes with BRVO. Untreated, only 14% of eyes with chronic macular edema will have a visual acuity (VA) of 20/40 or better. If not resolved spontaneously, treatment is necessary in the form of intravitreal injection of Anti-VEGF followed by Macular Grid Laser. Bevacizumab is the Anti-VEGF of choice in developing countries because of its prolonged action and cheap price, which helps in preventing neovascularisation and thus further haemorrhages. Laser helps in stopping the leakage and thus helps in treating the macular edema.

Aims and Objectives: The aim of the study is to evaluate the efficacy of intravitreal Bevacizumab and Macular grid laser in the management of macular edema secondary to Branch Retinal Vein Occlusion in patients attending the ophthalmology.

Materials and Methods: In this research study, 32 patients presenting with macular edema secondary to Branch Retinal Vein Occlusion to ophthalmology OPD were included after taking their consent and the study was carried out for a period of 2 years. Detailed history taking, Visual acuity, slit lamp examination, Fundus examination and OCT were done for all before treatment and also during every follow ups. FFA was done before treatment and after 3 months of laser. As treatment, all of them were given intravitreal injection of bevacizumab followed by macular grid laser.Patients were followed up on Day 1, Day 4, Day 7 and 4 weeks after intravitreal injection and 3 months after grid laser.

Results: In our study out of 32 patients, 17 were male (52%) and 15 were females (48%). The average age of the patient was 59 (range 40-70). The commonest co-morbidities in the patients were either Diabetes or Hypertension or both. The commonest type of BRVO was superotemporal BRVO. The average visual gain was statistically significant. The average decrease in Central Macular Thickness was 383 microns and this was statistically significant (p<0.05). There was no serious ocular or systemic complications following intravitreal injection of Bevacizumab in our study

Conclusion: In the management of macular edema secondary to Branch Retinal Vein Occlusion Intravitreal Bevacizumab injections in combination with subsequent macular grid treatment significantly improves vision and reduces macular edema.

Open Access Original Research Article

Demographic and Serum Alanine Aminotransferase level of Primary Health Care Workers Positive for Hepatitis B Surface Antigen and Hepatitis C Virus in Cross River North, Nigeria

Enaiho Oriasotie Sylvester, Ezeh Charles Ogbonna, Dic-Ijiewere Ebenezer Oseremen, Olerimi Samson, Ekhoye Ehitare

Journal of Advances in Medicine and Medical Research, Page 10-19
DOI: 10.9734/jammr/2022/v34i131244

Background: Healthcare workers (HCW) are perceived to be a high-risk group for hepatitis B due to occupational exposure to infected bodily fluids and often poor availability of protective equipment in sub-Saharan Africa. This study was carried out to assess the serums ALT levels of Primary Health Care workers (PHCW) who are reactive to Hepatitis B surface antigen, hepatitis C virus and evaluate their sociodemographic characteristics amongst.

Methods: The study was carried out in the health care centres of five (5) local government areas of Cross River North Senatorial district of Cross River State, Nigeria which includes Bekwarra, Obanliku, Obudu, Ogoja and Yala local government areas.  These primary health care centres provide medical services for patients diagnosed with Hepatitis B, Hepatitis C and HIV. Two hundred (200) health workers’ samples were analysed in the study.

Results: The result showed that 192 (96%) of the subjects tested negative to hepatitis B Virus while 8 (4%) were positive for the virus. Data also show that 198 (99%) of the subjects tested negative to Hepatitis C Virus while 2 (1%) were positive. Alanine aminotransferase decreased in subjects that tested positive to the Hepatitis B and C Virus.

Conclusion: The prevalence of hepatitis B surface antigen (HBsAg) and Hepatitis C amongst Health Care Workers was insignificant, and this could be attributed to the knowledge and attitude of the workers towards safety practices as well as vaccination.

Open Access Original Research Article

Surgical Outcomes of Bone Cement Augmented Screw Fixation, Cannulated Screws and Vertebroplasty in Osteoporotic Spine

Ibrahim Adel Sakr, Ebrahim Ahmed Shamhoot, Essam Abd El-Hay Mokbel, Ali Ibrahim Saif El-Deen, Ibrahim Mohamed Shafiq

Journal of Advances in Medicine and Medical Research, Page 20-29
DOI: 10.9734/jammr/2022/v34i131245

Background: osteoporosis is a common morbidity characterized by a systemic impairment of bone mass and microarchitecture that results in bone fragility fractures leading to decreased quality of life.

Methods: This study was conducted upon 30 adult patients with osteoporotic spine subjected to bone cement augmentation in the department of Neurosurgery, Tanta University Hospitals between January 2020 and January 2021.

Results: Oswestry Disability Index (ODI) ranged from 64-85 with mean 78±18.8 before surgery and 21-44 after surgery with mean 33±15.6. Visual Analog Scale for Pain (VAS) ranged from 7-9 pre-operatively with a mean value 8.2±1.8 and from 1-3 post-operatively with a mean value 2.3±1.6.

Open Access Original Research Article

Renoprotective Effect of Losartan Versus Enalapril in Children with Chronic Kidney Disease

Dina Hesham Aly El-Morsey Atyia, Shahinaz Mahmood Shams Addein, Shymaa Mohamed El Rifaey, Hend Hassan Abd Elnabi

Journal of Advances in Medicine and Medical Research, Page 30-42
DOI: 10.9734/jammr/2022/v34i131246

Background: Proteinuria is a marker of severity of chronic kidney disease)CKD) and leads to progression to end stage renal disease which can be reduced by blocking renin angiotensin aldosterone system(RAAS) through angiotensin converting enzyme inhibitors(ACEis) (e.g . enalapril) and angiotensin receptor blockers (ARBs) (e.g. losartan(

Aim of the Work: To evaluate the renoprotective effect of losartan versus enalapril in children with CKD.

Patients and Methods: This prospective cohort study was conducted on Sixty CKD children aged (5 to 17 years), were subdivided into three groups as the following: group I; 20 patients received enalapril, group II; 20 patients received losartan, group III; 20 patients didn’t receive losartan nor enalapril. All patients were subjected to thorough history, clinical evaluation and laboratory investigations (blood urea, serum creatinine, GFR, 24hours urinary  proteins, serum albumin, lipid profile and serum electrolytes) initially and after 6monthes of treatment.

Results: this prospective cohort study was conducted on 34males and 26 females CKD children. Steroid dependantnephrotic syndrome (SDNS) was the commonest cause (53.3%)followed by diabetic nephropathy (DN)(15%), lupus nephritis(LN) (12%) and only 1 case was frequent relapse NS (FRNS). protienuria improved with 76.7% reduction in losartan group versus 45.6%reduction in enalapril group after 6 months of treatment. GFR increased by( 4.5%,8.6%)  in losartan and enalapril groups respectively. Serum creatinine decreased by(11.6% and 8.3%) in losartan and enalapril groups respectively.

Conclusions: losartan and enalapril have a role in controlling proteinuria distinct from their  antihypertensive effect .

Open Access Original Research Article

A Study of Safety and Effectiveness of Intra Venous Iron Sucrose Therapy in Pregnant Women Suffering From Moderate to Severe Iron Deficiency Anaemia Disease

Heena Rajput, Kinnari Amin, Bhamini Kadikar, Nilesh Shah, Kalgi Shah, Ishan Shah

Journal of Advances in Medicine and Medical Research, Page 65-72
DOI: 10.9734/jammr/2022/v34i131249

Aims & Objectives: To determine the effectiveness and safety of IV Iron sucrose therapy in antenatal women with moderate to severe Iron deficiency anaemia.

Methodology: It is a retrospective study with secondary data analysis. We have analyzed the data collected from January 2019 to December 2019 at the Nootan general hospital, Visnagar, Gujarat, India. Analysis of antenatal  women with moderate to severe anaemia (Hb 6 to 8gm%) in the second trimester  and early third trimester(20 to 34weeks of gestation) are done during their  routine antenatal care  who were prescribed Intravenous Iron sucrose in a standard-dose of 1000 mg given as 200 mg on alternate days after confirming the iron deficiency anaemia. Effectiveness of the therapy has been studied by comparing the Hb level at the point baseline where start of the treatment and 4 week or more after the last treatment was given (endline). The safety profile of the therapy has been assessed by noticing any adverse drug reaction after starting the infusion.

Results: Mean increase in Hb in cases of moderate & severe anaemia was 3.69 g/dl (1.19) and 3.91 (1.25) g/dl respectively. Overall rise of Haemoglobin was 3.79 g/dl (1.1)(95% CL: 3.35, 4.23).  Calculated p value in our study is < 0.001 which is statistically significant.

Conclusion: The mean rise in Haemoglobin level in our study was 3.79 g/dL when 1000 mg of Intra venous iron sucrose was given to antenatal women with moderate as well as severe anaemia is concerned. The magnitude of the anaemia difference is directly proportional rise of haemoglobin level. The amount of haemoglobin rise is seen more in severe anaemic antenatal patients compared with moderate antenatal patients. We recommend that Intravenous iron sucrose therapy should be included as second choice for severely anaemic pregnant women where situation is not supportive for blood transfusion or patient is noncompliant.

Open Access Original Research Article

Value of First and Early Second Trimester Fetal Echocardiography and Fetal Nuchal Translucency Measurement in Prediction of Fetal Congenital Heart Diseases

Aya S. Nasr ElDin, Shereef L. ElShwaikh, Suzan B. ElHefnawy, Dina G. ElKholi

Journal of Advances in Medicine and Medical Research, Page 73-87
DOI: 10.9734/jammr/2022/v34i131250

Background: Congenital heart anomalies have a significant effect on affected children's life with up to 25:35% mortality rate during pregnancy and the postnatal period, and 60% of this mortality occurs during the first year of life.

Objectives: To evaluate the value of fetal echocardiography and measuring of fetal nuchal translucency thickness in first and early second trimester in prediction of fetal congenital heart disease.

Methods: A prospective observational cohort study was conducted on 200 pregnant women attended to Tanta University Hospital, Department of Obstetrics and Gynecology at outpatient clinic or inpatient, the study took from January 2019 to December 2020. Patients underwent transabdominal fetal echocardiography at 10:16 weeks of gestation. transvaginal scan was also performed when needed. The first step in fetal cardiac ultrasound is to evaluate the orientation of the fetal laterality (presentation and lie). Establishing situs and atrial arrangement, Five short-axis views of heart. First view is acquired in abdomen at level of stomach to identify situs.

Results: predict congenital heart disease (compared to results of first Echo), nuchal translucency had 83.33% sensitivity, 98.97% specificity, 71.43% PPV, 98.50% NPV and 99.48% accuracy.. predict congenital heart disease (compared to fetal outcome), nuchal translucency had 83.33% sensitivity,98.97% specificity, 71.43% PPV, 99.48%% NPV and 98.50% accuracy.

Conclusions: Fetal echocardiography and measuring of fetal nuchal translucency thickness in first and early second trimester have good sensitivity in prediction and better specificity in exclusion of fetal congenital heart diseases.

Open Access Original Research Article

Relationship between Knowledge and Practice of Physical Activity and Development of Chronic Diseases among Adults in Port Harcourt, Rivers State

Orukwowu Udo, Nwondah Chigozie, Wogu Dennis, Akpan Ido John

Journal of Advances in Medicine and Medical Research, Page 88-104
DOI: 10.9734/jammr/2022/v34i131251

Background: Non-communicable disease (NCD) is a disease that is not transmissible directly from one person to another. The aim study is to assess the relationship between knowledge and practice of physical activity and development of chronic diseases among adults in Port Harcourt, Rivers State.

Materials and Methods: The study was conducted among residents in Port Harcourt metropolis, Rivers State. A descriptive cross-sectional study design was used for this study. A multi-stage sampling method was used to recruit 333 participants into the study. The study included adults who were 45yrs and above at time of the data collection, and who must have lived in Port Harcourt for at least 1 year. All adults who were critically ill at the time of this study were excluded. A semi-structured questionnaire was used to collect responses from the participants. Information collected were entered into the Statistical Package for Social Science (SPSS) version 21 software as numeric codes and analyzed. Ethical clearance for the study was gotten from the Ethics Committee of Rivers State University and informed consent was obtained from all participants.

Result: This study found that majority of the participants, (64.9%) had good knowledge of physical activity while (35.1%) had poor knowledge physical activity. About (25.2%) of the participants engage in physical activity, while (53.6%) of them regularly do physical activity. The result showed that a statistically significant association was observed between tobacco consumption at (p=0.0001), alcohol consumption at (p=0.0001) and chronic diseases. Also a statistically significant relationship between knowledge of physical activity and chronic disease.

Conclusion: This study concludes that there is a significant relationship between lack of exercise and development of chronic diseases. Also, socio-demographic characteristics and social lifestyle of the respondents have a great influence on physical activity, development and progression of chronic diseases among adults. The study recommends that health workers should organize regular health education and promotion on physical activity among adults in Port Harcourt and other parts of the country.

Open Access Original Research Article

Knowledge of Sexual and Reproductive Health among Adolescents in a Ghanaian Municipality: A Mixed-Method Approach

Charles Owusu-Aduomi Botchwey, Francis Acquah, Richmond Opoku, Agartha Afful Boateng, Michael Afari Baidoo

Journal of Advances in Medicine and Medical Research, Page 105-117
DOI: 10.9734/jammr/2022/v34i131252

Introduction: Sexual and Reproductive Health (SRH) is an essential aspect of the physical, mental, social, and emotional well-being of adolescents who are generally known to be the most vulnerable group in this aspect of health.

Aim: This study was designed to explore the sexual and reproductive health knowledge of adolescents in the Central Region of Ghana with Komenda as the case study.

Methodology: A mixed method with a case study design was adopted through quantitative survey and focus group discussions among 95 adolescents in the Komenda community.

Results and Discussion: The study revealed that most respondents had an idea about what SRH is all about, what contraceptives are with condom being known by all of the study respondents but were not willing to use contraceptives during sex. Most respondents also knew of STDs including HIV and their mode of transmission even though a significant number of the respondents (for example, 34% of survey respondents) were also found to hold misconception that STDs can be transmitted through witchcraft. The school was found to be the most source of SRH information for the respondents and place they will prefer to learn about SRH. Who to best discuss SRH issues with was found to depend on the type of SRH issue to be shared even though parents followed by peers and health professionals were found to be the entities survey respondents generally would prefer to share SRH issues with.

Conclusion: This study revealed that even though respondents had knowledge on SRH, most of them held some misconceptions about SRH which is likely to affect their understanding and tolerance of the topic. This can lead to poor SRH outcomes such as high prevalence of HIV/AIDS. There is therefore the need for effective education among adolescents in the study community by the Ghana Health Service and relevant stakeholders. Moreover, the school should be used as an important vessel for educating adolescents on SRH issues.

Open Access Original Research Article

Role of Immunity in Pediatric Drug Resistant Epilepsy: Clinical, Neurophysiological, Neuroimaging and Immunological Study

Nema A. Labib, Wael A. F. Abd El-Rahman, Tarek M. El-Gammal, Ehab A. S. El-Seidy, Gehan F. Ateya

Journal of Advances in Medicine and Medical Research, Page 118-126
DOI: 10.9734/jammr/2022/v34i131253

Introduction: Autoimmune epilepsy was an under-recognized condition, and its true incidence was unknown in pediatrics. Serum antibodies suggesting a potential autoimmune etiology were detected in 34.8% of patients presented by epilepsy of unknown etiology. Diagnosis of autoimmune epilepsy would be of great value in the search for potential preventive treatments for disabling seizures and cognitive impairment.

Autoimmune epilepsy was characterized by a depressed or altered level of consciousness, lasting more than 24 h, lethargy, or change in personality or behavior and at least one of the following features: neuropsychiatric symptoms, seizures, movement disorder, or cognitive dysfunction. Patients were excluded if an alternative diagnosis was made. The presence of neuronal antibodies and MRI changes supported the diagnosis. This study aimed to assess the possible role of immunity in the pathogenesis of pediatric drug resistant epilepsy through clinical electroencephalographic, neuroimaging and neuro-immunological testing.

Subjects and Methods: This study was conducted on twenty-four drug resistant epileptic children with suspected autoimmune etiology over the period from 2016-2018. The control group comprised twenty four children with idiopathic controlled epilepsy matched to the drug-resistant epilepsy sample for age and gender. Both groups were subjected to clinical examination, neuronal antibodies in serum and CSF, Mini-Mental State Examination (MMSE), Chalfont seizure severity scale (CSSS), EEG, and brain MRI studies.

Results: There was a large percentage of autoimmune epilepsy in pediatric cryptogenic drug-resistant epilepsy. 55% of DRE cases presented with mild pleocytosis and elevated CSF proteins. Serum and CSF neuronal antibodies were positive in about 66.63% and 65% of cases respectively. Serum neuronal antibodies to GAD were positive in 8.33%, NMDA Abs were positive in 33.3%, and VGKC Abs were in 25.0% of cases. In the CSF, GAD antibodies were positive in 10%, NMDA antibodies in 40%, and VGKC antibodies in 20% of cases. Seizures reduction was achieved with immunotherapy, also was prevalent in seropositive cases.

Conclusion: Pediatric patients presented by drug-resistant epilepsy should receive immunotherapy for a definite diagnosis. MRI changes in the form of temporal hyperintensity, claustrum, cortical hyperintensities were a common finding in pediatric patients presented by drug-resistant epilepsy. CSF changes in the form of elevated proteins and /or mild pleocytosis signified inflammatory changes in the CNS and blood brain barrier (BBB) disruption. Steroid responsiveness played a major role in the diagnosis of autoimmune epilepsy, especially seronegative cases.

Open Access Original Research Article

Effect of Preoperative Single Dose Misoprostol on Intraoperative Blood Loss during Abdominal Hysterectomy: A Randomized Controlled Trial

Asmaa Ezzat Abdel Aziz, Aml Abdel Samea El Sokary, Hesham Mohamed El Said Borg, Safaa Kamal Marey

Journal of Advances in Medicine and Medical Research, Page 127-134
DOI: 10.9734/jammr/2022/v34i131254

Background: Hysterectomy is the surgical removal of the uterus. It is the most frequently performed major gynaecological surgical procedure, with millions of procedures performed annually throughout the world. Hysterectomy can be performed for benign and malignant indications. Misoprostol, a synthetic analogue of prostaglandin E1, has been extensively evaluated as a uterotonic agent in obstetrics mainly for prevention and management of postpartum haemorrhage and reduction of bleeding during caesarean delivery. The purpose of this research is to evaluate the impact and efficacy of pre-operative sublingual misoprostol given in women having hysterectomy in terms of blood loss.

Results: This randomized single blind controlled trial was carried on 70 women undergoing total abdominal hysterectomy. They were randomly allocated in two equal groups: misoprostol group: patients received two tablets of Misoprostol (=200 μg) 30 minutes before operation and a control group (placebo group): patients received two tablets of Placebo 30 minutes before            operation.

Haemoglobin and Haematocrit reductions were significantly lower among misoprostol group than among placebo group. Blood loss was significantly lower among misoprostol group than among placebo group. The most common indication for hysterectomy was a fibroid, dysfunction uterine bleeding and, adenomyosis. The fibroid was the most significant for the effect of misoprostol in decreasing blood loss, haemoglobin and haematocrit during abdominal hysterectomy more than adenomyosis and dysfunction uterine bleeding.

Conclusions: A single preoperative dose of 400 μg of misoprostol administered 30 minutes before abdominal hysterectomy resulted in a significant reduction of blood loss.

Open Access Review Article

Importance of Human Milk for Health and as Antiviral Immunotherapy - A Narrative Review

Prameela Kannan Kutty

Journal of Advances in Medicine and Medical Research, Page 51-64
DOI: 10.9734/jammr/2022/v34i131248

Background: Immunological protection against novel mucosal pathogens is crucial to us as our immunity is unable to effectively defend against specific pathogens without previous immune encounters, as experienced in the SARS-CoV-2 pandemic. However, a nursing neonate is protected from many novel infections by exclusive human milk feeding despite having a naïve immune system without much previous pathogen exposure. It is observed that SARS-CoV-2 is not transmitted to the nursing infant through human milk and that natural maternal infections produce specific antibody responses in human milk. Furthermore, maternal vaccination against SARS-CoV-2 may modify some of these responses compared to natural infections. In this setting, it was felt necessary to also explore if early, innate immunity in human milk can protect against SARS-CoV-2.To explore this hypothesis, I reviewed the pathogenic mechanisms of COVID-19 focusing on the methods of viral entry through the human mucosae, infection establishment, immune dysregulation, and disease causation, and integrated these with the early actions by human milk feeding on mucosal infections. I then extrapolated the relevant pathways of human milk immune protection as potentials to protect against SARS-CoV-2.

Methods: This was divided into three steps which firstly included a literature search, secondly a stepwise analysis and synthesis of data, and thirdly, an integration of data to form a hypothesis. The first step searched articles in two areas. In the first area, articles included were on the infection and pathogenesis of SARS-CoV-2, and in the second area, articles included were on innate immunity in human milk. In the second step, I analyzed the immunological actions in human milk against mucosal infections, on the whole, and synthesized some of these relevant actions against the pathogenesis of SARS-CoV-2 infections. In the third step, I integrated human milk immune pathways that could interfere with the establishment of SARS-CoV-2 infection, viral invasion, immune dysregulation, and the progression of the disease.

Results: Infection by SARS-CoV-2 can theoretically be reduced or mitigated by the effect of early immune constituents in human milk. Human milk feeding may confer protection against all stages of the disease including the establishment of SARS-CoV-2 infection, invasion, and immune dysregulation and these actions may benefit both the individual and the community.

Limitations: The multifunctional and dynamic nature in which human milk constituents function in a nursing infant cannot be fully reproduced by studying isolated components under experimental conditions. Even when such factors can theoretically offer protection against the virus, this concept has to be further researched in large cohorts of nursing infants.

Conclusion: The role of human milk in preventing infection by SARS-CoV-2 must be explored further and if true, exclusive human milk feeding must be considered another reason for the smaller number of infections observed in children compared to adults in the pandemic. The additional counseling of human milk feeding for protection against novel pathogens, besides its established role in reducing neonatal mortality, would enhance rates of exclusive human milk feeding. General health can be developed and promoted through the potential immunotherapy provided by it.