Anemia and HIV in the Antiretroviral Era: Potential Significance of Testosterone.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 3722-3722
Author(s):  
Caroline M. Behler ◽  
Starley B. Shade ◽  
Kellan Gregory ◽  
Donald I. Abrams ◽  
Paul A. Volberding
Keyword(s):  
Logistic Regression ◽  
Antiretroviral Therapy ◽  
Confidence Intervals ◽  
Opportunistic Infections ◽  
P Value ◽  
Hiv Disease ◽  
Odds Ratios ◽  
Multivariable Logistic Regression Model ◽  
Testosterone Levels ◽  
Low Testosterone

Abstract BACKGROUND: Anemia remains the most common hematologic disorder in human immunodeficiency virus (HIV) infection despite the use of effective antiretroviral therapy, and is associated with decreased quality of life and survival. Hypogonadism is prevalent in advanced HIV disease, however low testosterone levels have not been customarily implicated in HIV-associated anemia. This study was undertaken to determine whether there is a relationship between testosterone levels and androgen use with anemia in HIV, and to characterize other clinical correlates of HIV-associated anemia. METHODS: This cross-sectional study examined the clinical characteristics of 200 HIV positive patients at a public hospital HIV clinic and clinical features associated with anemia. A written questionnaire detailed previous and current medication use, opportunistic infections and malignancies. Hematologic and virologic parameters, testosterone and erythropoietin levels were measured; CD4 count and viral load nadir and peak levels were obtained from the computerized medical record. Anemia was defined as hemoglobin <13.5 g/dL in men and <11.6 g/dL in women. RESULTS: Anemia was present in 24% of women and 28% of men. Anemia was negatively associated with female sex (adjusted OR 0.30, 95% CI 0.11–0.85), current antiretroviral therapy (adjusted OR 0.43, 95% CI 0.20–0.95), current androgen use (adjusted OR 0.20, 95% CI 0.05–0.84) and macrocytosis (adjusted OR 0.23, 95% CI 0.09–0.61). Anemia was positively associated with lymphopenia (adjusted OR 4.0, 95% CI 1.36–11.80), high erythropoieitin levels (adjusted OR 7.73, 95% CI 2.92–20.48) and low testosterone levels (adjusted OR 3.27, 95% CI 1.01–10.60). CONCLUSIONS: Low testosterone levels may have a positive association, and supplemental androgens a negative association with anemia in HIV disease. Predictors of Anemia Unadjusted odds ratios and 95% confidence intervals obtained by logistic regression. Variables that achieved a p-value of <0.1 in tests of interaction were included in a multivariable logistic regression model, which was used to obtain adjusted odds ratios and 95% confidence intervals. N % Anemic Unadjusted OR (95% CI) Adjusted OR (95% CI) Female 38 23.7 0.78 (0.34, 1.78) 0.30 (0.11, 0.85) Male/MTF Transgender 162 28.4 Lymphopenia (<1.0x109/L) 19 57.9 3.05 (1.24, 7.51) 4.00 (1.36, 11.80) Normal Lymphocyte Count 178 24.7 Macrocytosis (MCV>100fL) 71 14.1 0.34 (0.16, 0.74) 0.23 (0.09, 0.61) Normal MCV 117 32.5 Microcytosis (MCV<80fL) 11 63.6 2.91 (0.87, 9.77) 2.02 (0.50, 8.13) Current Antiretroviral Therapy 139 20.1 0.32 (0.17, 0.61) 0.43 (0.20, 0.95) No current Antiretroviral Therapy 61 44.3 Current Androgen Use 23 13.0 0.36 (0.10, 1.27) 0.20 (0.05, 0.84) No Current Androgen Use 171 28.7 EPO x Testosterone Interaction High EPO-High/nl Testosterone 46 41.3 2.50 (1.23, 5.11) 7.73 (2.92, 20.48) Low/nl EPO-Low Testosterone 24 37.5 2.39 (0.89, 6.39) 3.27 (1.01, 10.60) High EPO-Low Testosterone 11 27.3 0.33 (0.04, 2.50) 0.17 (0.012, 2.36) Low/nl EPO-High/nl Testosterone 115 20.9

Female Authorship in Radiology: Trends in the Past Decade in CARJ

2020 ◽  
pp. 084653712094664
Author(s):  
Nicole Li ◽  
Mostafa Alabousi ◽  
Michael N. Patlas
Keyword(s):  
Logistic Regression ◽  
Statistical Analysis ◽  
P Value ◽  
Inclusion Criteria ◽  
Odds Ratios ◽  
The Past ◽  
Single Author ◽  
Canadian Association ◽  
Female Authorship ◽  
Over Time

Purpose: To identify trends in female authorship in the Canadian Association of Radiologists Journal (CARJ) from 2010 to 2019. Methods: We retrieved papers published in the CARJ over a 10-year period, and retrospectively reviewed 602 articles. All articles except editorials and advertisements were included. We categorized the names of the first and last position authors as female or male and excluded articles that had at least one author of which gender was not known. We compared the trends in the first and last position authors of the articles from 2010 to 2019. For statistical analysis, logistic regression was performed with reported odds ratios (ORs), and a P value of <.05 was defined as statistically significant. Results: Five hundred thirteen articles met inclusion criteria. Among them, 23 articles with a single author were classified as having only a first author. 39.8% (204/513) of first authors were female and 26.9% (132/490) of last authors were female. There has been an overall temporal increase in the odds of both the first and last author being female in CARJ publications (OR: 1.11, P = .034). Similarly, the odds a CARJ publication’s first author being female increased over time (OR: 1.07, P = .033). Female last author did not predict female first author (OR: 1.48, P = .056). There was no association identified between female last author and year of publication (OR: 1.04, P = .225). Conclusion: There has been an overall increase in engagement of female authorship in CARJ.

Abstract 114: Effect of Sodium Bicarbonate on Advanced Cardiac Life Support

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Jungyoup Lee
Keyword(s):  
Logistic Regression ◽  
Sodium Bicarbonate ◽  
Life Support ◽  
Conditional Logistic Regression ◽  
Advanced Cardiac Life Support ◽  
Spontaneous Circulation ◽  
Rank Test ◽  
P Value ◽  
Multivariable Logistic Regression Model ◽  
Routine Administration

Introduction: Current guidelines do not support routine administration of sodium bicarbonate during cardiopulmonary resuscitation (CPR). Previous studies did not recommend bicarbonate unless there is severe metabolic acidosis or hyperkalemia. We hypothesized that the sodium bicarbonate, regardless of its effect on long-term outcomes, may improve the chance of achieving return-of-spontaneous circulation (ROSC). Methods: We used out of cardiac arrest registry in our hospital and analyzed retrospectively. The primary endpoint was to assess the association between 1) the timing first administration as well as 2) the total amount of sodium bicarbonate administered until ROSC and the chance of achieving ROSC. The secondary endpoint was to assess whether there is significant decrease in early survival if sodium bicarbonate was administered during CPR. We built multivariable logistic regression model by the use of the amount of sodium bicarbonate, age, initial base deficit, serum potassium level and usual Utstein template factors with their p-value < 0.1 in univariable analysis. Results: Total 697 patients were enrolled. The amount of sodium bicarbonate administered until ROSC (or CPR termination if there is no ROSC) was significantly associated with the chance of ROSC (Odds ratio [OR], 1.10; 95% confidence interval [CI], 1.01-1.19; p=0.028). The association was still valid after additional adjustment with factors with their p-value < 0.1 in univariable conditional logistic regression analysis. (OR, 1.14; 95% CI, 1.01-1.29; p=0.031) The time to first administration of sodium bicarbonate did not show significant univariable association (OR, 0.99; 95% CI, 0.99-1.00; p=0.193). Kaplan-Meyer survival curves showed significantly increased death rate in patients administered with sodium bicarbonate (log-rank test, p=0.002) Conclusion: Administration of higher dose of sodium bicarbonate during CPR was associated with increased chance of achieving ROSC. However, such benefit was negated soon after by higher early mortality rate in the group where sodium bicarbonate was administered.

Time to Switching to Second-line Antiretroviral Therapy and Its Predictors Among HIV/AIDS Infected Children at General Hospitals, Northern Ethiopia: A Survival Analysis

2021 ◽  
Author(s):  
Migbar Sibhat ◽  
Tewodros Mulugeta ◽  
Dawit Aklilu
Keyword(s):  
Antiretroviral Therapy ◽  
Opportunistic Infections ◽  
Rank Test ◽  
P Value ◽  
Northern Ethiopia ◽  
Second Line ◽  
Cox Proportional Hazard Regression ◽  
Adherence Monitoring ◽  
Second Line Antiretroviral Therapy

Abstract BackgroundWith expanding access to pediatric antiretroviral therapy, a growing amount of patients in the developing world has switched to second-line therapy, and some requiring third-line medications. A delay in switch increases mortality and risk of developing opportunistic infections. There remain limited and often conflicting estimates on the use of second-line ART in children. Thus, this study intended to determine the incidence and predictors of switching to second-line antiretroviral therapy among children.MethodsRetrospective follow up study was conducted by reviewing all charts. Data were collected by extraction tool; entered using Epi-data; cleaned and analyzed by STATA V-14. Kaplan-Meier curve, log-rank test, and life table were used for data description and adjusted hazard ratios and p-value for analysis by Cox proportional hazard regression. Any variable at P≤0.25 in the bi-variable analysis was taken to multivariate analysis and significance was declared at P≤0.05. Data were presented using texts, tables, and figures.Results and conclusionAnalysis was conducted on 424 charts with total person-time observation of 11686.1 child-months and incidence switch rate of 5.6 (95% CI 4.36-7.09) per 1000 child-month-observations. Being orphaned [AHR=2.36; 95%CI: 1.10-5.07], suboptimal ART adherence [AHR= 2.10; 95% CI: 1.12-3.92], drug toxicity [AHR= 7.05; 95% CI: 3.61-13.75], advanced recent WHO stage [AHR=2.75; 95%CI: 1.05-7.15], and initiating ART with TB co-infection [AHR=3.08; 95%CI: 1.26-7.51] were significantly associated with switch to second-line ART regimen. Moreover, long duration of ART follow up [AHR=0.75; 95% CI: 0.71-0.81] was found to be protective against switching. Hence, it is better to give priority for strengthening the focused evaluation of tuberculosis co-infection and treatment failure with continuous adherence monitoring. Further research is also needed to evaluate the effect of drug resistance.

scholarly journals The applicability of basic preventive measures of the pandemic COVID-19 and associated factors among residents in Guraghe Zone

PLoS ONE ◽  
2021 ◽  
Vol 16 (8) ◽  
pp. e0256598
Author(s):  
Samuel Dessu ◽  
Tadesse Tsehay ◽  
Tadele Girum ◽  
Abebe Timerga ◽  
Mamo Solomon ◽  
...  
Keyword(s):  
Public Health ◽  
Logistic Regression ◽  
Regression Model ◽  
Family Size ◽  
Associated Factors ◽  
Logistic Regression Model ◽  
Preventive Measures ◽  
P Value ◽  
Multivariable Logistic Regression Model ◽  
Poor Knowledge

Introduction Internationally, countries have reacted to the COVID-19 outbreak by introducing key public health non-pharmaceutical interventions to protect vulnerable population groups. In response to COVID-19, the Government of Ethiopia has been taking a series of policy actions beyond public health initiatives alone. Therefore, this study was aimed to assess the applicability of basic preventive measures of the pandemic COVID-19 and associated factors among the residents of Guraghe Zone from 18th to 29th September, 2020. Methods Community based cross sectional study was conducted at Guraghe Zone from 18th to 29th September, 2020. Systematic random sampling method was applied among the predetermined 634 samples. Variables which had p-value less than 0.25 in bivariate analysis were considered as candidate for multivariable logistic regression model. P-value <0.05 was used as a cutoff point to determine statistical significance in multiple logistic regressions for the final model. Result In this study, 17.7% (95% CI: 14.7, 20.5) of the respondents apply the basic preventive measures towards the prevention of the pandemic COVID-19. In addition, being rural resident (AOR: 4.78,; 95%CI: 2.50, 8.90), being studied grade 1–8 (AOR: 3.70; 95%CI: 1.70, 7.90), being a farmer (AOR: 4.10; 95%CI: 1.25, 13.35), currently not married (AOR: 2.20, 95%CI: 1.24, 4.06), having family size 1-3(AOR: 6.50; 95%CI: 3.21, 3.35), have no diagnosed medical illness (AOR: 6.40; 95%CI: 3.85, 10.83) and having poor knowledge (AOR: 3.50; 95%CI: 1.60, 7.40) were factors which are statistically significant in multivariable logistic regression model. Conclusion Despite the application of preventive measures and vaccine delivery, the applicability of the pandemic COVID-19 preventive measures was too low, which indicate that the Zone is at risk for the infection. Rural residents, those who have lower educational level, farmers, non-marrieds, those who have lower family size, those who have diagnosed medical illnesses and those who have poor knowledge were prone to the infection with the pandemic COVID-19 due to the lower practice of applying the basic preventive measures. In addition, awareness creation should be in practice at all levels of the community especially lower educational classes and rural residents.

scholarly journals The Visitor and Migrant Cost Recovery Programme – A threat to health?

2020 ◽  
Author(s):  
Jessica Louise Potter ◽  
Matthew Burman ◽  
Conor D Tweed ◽  
D Vaghela ◽  
H Kunst ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Median Time ◽  
Diagnostic Delay ◽  
Cost Recovery ◽  
P Value ◽  
Programme Implementation ◽  
Multivariable Logistic Regression Model ◽  
Time To Treatment ◽  
Tb Treatment ◽  
The Uk

Abstract Background In April 2014 the UK government launched the ‘NHS Visitor and Migrant Cost Recovery Programme Implementation Plan’ which set out a series of policy changes to recoup costs from ‘chargeable’ (largely non-UK born) patients. In England, approximately 75% of tuberculosis (TB) cases occur in people born abroad. Delays in TB treatment increase risk of morbidity, mortality and transmission in the community. We investigated whether diagnostic delay has increased since the Cost Recovery Programme (CRP) was introduced. Methods There were 3,342 adult TB cases notified on the London TB Register across Barts Health NHS Trust between 1st January 2011 and 31st December 2016. Cases with missing relevant information were excluded. The median time between symptom onset and treatment initiation before and after the CRP was calculated according to birthplace and compared using the Mann Whitney test. Delayed diagnosis was considered greater or equal to median time to treatment for all patients (79 days). Univariable logistic regression was used to manually select exposure variables for inclusion in a multivariable model to test the association between diagnostic delay and the implementation of the CRP. Results We included 2,237 TB cases. Among non-UK born patients, median time-to-treatment increased from 69 days to 89 days following introduction of CRP (p<0.001). Median time-to-treatment also increased for the UK-born population from 75.5 days to 89.5 days (p=0.307). The multivariable logistic regression model showed non-UK born patients were more likely to have a delay in diagnosis after the CRP (adjOR 1.37, 95% CI 1.13-1.66, p value 0.001) Conclusion Since the introduction of the CRP there has been a significant delay for TB treatment among non-UK born patients. Further research exploring the effect of policies restricting access to healthcare for migrants is urgently needed if we wish to eliminate TB nationally.

scholarly journals Magnitude of non-adherence to antiretroviral therapy and associated factors among adult people living with HIV/AIDS in Benishangul-Gumuz Regional State, Ethiopia

PeerJ ◽  
2020 ◽  
Vol 8 ◽  
pp. e8558
Author(s):  
Fikadu Tadesse Nigusso ◽  
Azwihangwisi Helen Mavhandu-Mudzusi
Keyword(s):  
Logistic Regression ◽  
Antiretroviral Therapy ◽  
Food Insecurity ◽  
Opportunistic Infections ◽  
Residential Area ◽  
People Living With Hiv ◽  
Economic Factors ◽  
Factors Associated ◽  
Living With Hiv ◽  
Hiv Aids

Introduction Following global efforts to increase antiretroviral therapy (ART) access and coverage, Ethiopia has made significant achievement with a 6.3% annual decline in the HIV/AIDS incidence rate between 1990 and 2016. Such success depends not only on access to ART but also on attaining optimum treatment adherence. Emerging studies in Ethiopia has shown the increasing prevalence of poor adherence and lack of the desired viral suppression, but the extent and factors associated with non-adherence to ART are not well known, especially in the current study setup. In this study, we examined the magnitude and factors associated with treatment and non-adherence to ART among people living with HIV in Benishangul-Gumuz Regional State, northwest Ethiopia. Methods An institutional facility based cross-sectional descriptive study was carried out among adult people living with HIV/AIDS from mid-December 2016 to February 2017 with only 98.9% response rate. Sociodemographic factors (age, gender, marital status and residential area), economic factors (educational status, income, asset possession, employment status, dietary diversity, nutritional status and food security), and clinical characteristics (CD4 count, duration on ART and history of opportunistic infections) were explanatory variables. ART non-adherence was measured using a visual analogue scale (VAS). We used binary logistic regression and subsequent multivariate logistic regression analysis to determine the factors associated with ART non-adherence. Result Overall, 39.7% of the participants were found non-adherent to ART. Strong association was found between non-adherence to ART and young age below 25 years (AOR: 4.30, 95% CI [1.39–3.35]; p = 0.011), urban residential area (AOR: 2.78, CI [1.23–7.09], p = 0.043), lack of employment (AOR: 1.75, 95% CI [1.05–2.91], p = 0.032), food insecurity (AOR: 2.67, 95% CI [7.59–8.97]; p < 0.0001), malnutrition (AOR: 1.55, 95% CI [1.94–2.56]; p = 0.027) and opportunistic infections (AOR: 1.81, 95% CI [1.11–2.97]; p = 0.018). Conclusion The prevalence of non-adherence to ART in this study was high. Sociodemographic and economic factors such as young age of below 25 years, urban residential area, lack of employment, food insecurity, malnutrition and opportunistic infections were among the factors associated with non-adherence to ART.

Factors associated with childbearing intention of women on Antiretroviral Therapy in Northwest Ethiopia: A cross sectional study

2020 ◽  
Author(s):  
Amare Simegn Ayele ◽  
Demeke Mesfin Belay ◽  
Biniam Minuye Birihane
Keyword(s):  
Logistic Regression ◽  
Antiretroviral Therapy ◽  
Information Needs ◽  
Statistical Significance ◽  
Cross Sectional Study ◽  
P Value ◽  
Fertility Desire ◽  
Sectional Study ◽  
Hiv Diagnosis ◽  
Cross Sectional

Abstract Background: Though, childbearing intention is normal, it is imperative in Human Immune Virus positive women and identifying their intention has significant in reducing mother to child transmission. This study was intended to assess childbearing intention and associated factors among women on antiretroviral therapy in South Gondar Hospitals, Northwest Ethiopia.Methods: Institution based cross sectional study was employed. The sample for each Hospitals was allocated proportionally. Systematic random sampling method was used to select the study participants. Data were coded and entered into epidata 4.2 software and exported to statistical package for social sciences version 25 for analysis. Binary logistic regression was used to saw the association between each independent variable and dependent variable. All variables with P-value < 0.25 during bi-variable analyses were considered for multivariable logistic regression analyses. Odds ratio along with 95%CI were estimated to measure the strength of the association. Level of statistical significance was declared at p value less or equal to 0.05.Results: - A total of 418 women on antiretroviral therapy participated in the study. Child bearing intention was 42.6%. History of pregnancy after HIV diagnosis [Adjusted Odd Ratio (AOR) =5.19, 95% CI: (1.83, 14.7)], Partners fertility desire [AOR=10.99, 95% CI: (4.34, 27.86)], having alive children [AOR=0.23, 95% CI: 0.23(0.81, 0.63)] were significantly associated with childbearing intention.Conclusion. Childbearing intention of women on antiretroviral treatment was low. Having partner’s fertility desire, had pregnancy after HIV diagnosis and have alive child were significantly associated with childbearing intention. Information needs to be shared for the clients by using counseling protocols developed to achieve their desired reproductive goals.

Relationship of opioid analgesic (OA) use at 3 months and overall survival in patients (pts) with metastatic castration-resistant prostate cancer (mCRPC).

2012 ◽  
Vol 30 (5_suppl) ◽  
pp. 200-200 ◽  
Author(s):  
Susan Halabi ◽  
William Kevin Kelly ◽  
Ellen B Kaplan ◽  
Eric Jay Small
Keyword(s):  
Overall Survival ◽  
Logistic Regression ◽  
Proportional Hazards Model ◽  
Linear Trend ◽  
Opioid Analgesic ◽  
Prognostic Significance ◽  
Phase Iii ◽  
P Value ◽  
Castration Resistant Prostate Cancer ◽  
Multivariable Logistic Regression Model

200 Background: Baseline pain has been shown to be a significant predictor of overall survival (OS) in mCRPC pts. The objectives of this analysis were to identify predictors of OA use at 3-months after initiating frontline chemotherapy, and to determine if OA use at 3-months predicts overall OS in mCRPC pts. Methods: Data from CALGB 90401, a phase III trial of 1,050 mCRPC pts randomized with equal probability to receive docetaxel, prednisone with either bevacizumab or placebo was analyzed. OA use was collected at baseline and at 3-month follow-up. OA use was classified as: pts not on OA at baseline and at 3-months (OA1); OA at baseline but not on at 3-months (OA2); No OA at baseline but on OA at 3-months (OA3); and OA at both time points (OA4). The logistic regression method was utilized to identify predictors of OA use at 3-months. Furthermore, the proportional hazards model was used to assess the prognostic significance of OA use in predicting OS adjusting for stratification factors. Results: 836 pts had complete OA data. The overall distribution of pts with the associated median survival times is presented in the table. There was a linear trend between OA use and overall survival (log-rank p-value<0.0001). The multivariable hazard ratio (HR) for death was 1.34 (95% CI=1.12-1.61) comparing OA4 vs. OA1. In multivariable logistic regression model, statistically significant predictors of OA at 3-months were OA use at baseline, hemoglobin, and alkaline phosphatase. Conclusions: The strongest predictor of OA use at 3-months was use at baseline. In addition, this analysis shows that OA use after initiating chemotherapy is a statistically significant predictor of overall survival in mCRPC pts. These results require prospective validation. [Table: see text]

scholarly journals Hypogonadotropic hypogonadism in human immunodeficiency virus-infected men: uncommonly low testosterone levels

2017 ◽  
Vol 2017 ◽  
Author(s):  
Ana Coelho Gomes ◽  
José Maria Aragüés ◽  
Sílvia Guerra ◽  
Joana Fernandes ◽  
Mário Rui Mascarenhas
Keyword(s):  
Antiretroviral Therapy ◽  
Highly Active Antiretroviral Therapy ◽  
Pubertal Development ◽  
Hypogonadotropic Hypogonadism ◽  
Severe Illness ◽  
Testosterone Replacement Therapy ◽  
List Type ◽  
Testosterone Levels ◽  
Pituitary Dysfunction ◽  
Low Testosterone

Summary Hypogonadotropic hypogonadism (HH) is common and occurs prematurely in HIV-infected men. However, HH with very low testosterone has not been described. Three men with normal pubertal development and HIV1 diagnosis at the ages of 22, 34 and 35 years. All complained of decreased libido, anejaculation and erectile dysfunction thirteen years, six months and one year after HIV diagnosis, respectively. Two had depressive syndrome and two were treated with antiretroviral therapy. Laboratory tests revealed isolated HH in all. Sellar and head CT scans were normal and all had normal CD4 count. They started testosterone replacement therapy, with symptoms improvement. Causes of HH in HIV-infected men include undernutrition, severe illness, drugs, pituitary dysfunction and comorbidities. Despite having none of these conditions (except two that were treated with low-dose psychotropics), our patients had HH with uncommonly low testosterone. This suggests that a different mechanism contributes to severe HH in HIV-infected men. Learning points: The pathogenesis of hypogonadotropic hypogonadism in HIV-infected men is multifactorial and androgen deficiency is more often a consequence of secondary hypogonadism than primary hypogonadism. Causes of hypogonadotropic hypogonadism in HIV-infected men include undernutrition, severe illness, drugs (psychotropics, opiates, megestrol acetate or steroids), pituitary dysfunction (tumor, hyperprolactinemia), an AIDS-related lesion (very rarely) and comorbid conditions, such as antibody to hepatitis C virus seropositivity and injection drug use. Highly active antiretroviral therapy (HAART), particularly protease inhibitor therapy has been associated with sexual dysfunction in men, but the causal nature of this relation has not been clearly established. Hypogonadotropic hypogonadism with uncommonly low testosterone levels are not usually associated with the conditions referred and this suggests that a different mechanism could contribute to severe hypogonadotropic hypogonadism in HIV-infected men. Screening for hypogonadism in all HIV-infected men might help to understand its etiology.

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