NR 507 PATHOPHYSIOLOGY WEEK 1 TD1 (NR507)

Exam (elaborations) NR 507 PATHOPHYSIOLOGY WEEK 1 TD1 (NR507) Week 1: Altered Immune System and Altered Inflammatory - Discussion Part One Response Loading... This week's graded topics relate to the following Course Outcomes (COs). 1 Analyze pathophysiologic mechanisms associated with selected disease states. (PO 1) 2 Differentiate the epidemiology, etiology, developmental considerations, pathogenesis, and clinical and laboratory manifestations of specific disease processes. (PO 1) 3 Examine the way in which homeostatic, adaptive, and compensatory physiological mechanisms can be supported and/or altered through specific therapeutic interventions. (PO 1, 7) 6 Distinguish risk factors associated with selected disease states. (PO 1) 5 Describe outcomes of disruptive or alterations in specific physiologic processes. (PO 1) 6 Distinguish risk factors associated with selected disease states. (PO 1) 7 Explore age-specific and developmental alterations in physiologic and disease states. (PO 1, 4) Discussion Discussion Part One (graded) NR 507 PATHOPHYSIOLOGY WEEK 1 TD1 John is a 19-year-old college football player who presents with sneezing, itchy eyes, and nasal congestion that worsens at night. He states that he has a history of asthma, eczema and allergies to pollen. There is also one other person on the football team that has similar symptoms. His vitals are BP 110/70, P 84, R 18, T 100 F. Write a differential of at least five (5) possible items from the most likely to less likely. For each disease include information about the epidemiology, pathophysiology and briefly argue why this disease fits the presentation and why it might not fit the presentation. Responses Rechel DelAntar 4/26/2016 7:11:48 PM Introduction Hello Professor and Class, I would like to greet everyone a warm Hello and hope everyone is doing great. My name is Rechel Delantar and I have been a nurse for what seems like ages (graduated 1990). I have been in critical care and recovery room for most of my nursing career. The last 12 years I have specialized in Cardiovascular Recovery Room caring for post Heart Assist device, ECMOs, open hearts and organ transplant patients among others before moving to my current position as a Heart transplant coordinator. I have always wanted to pursue my masters degree but found it difficult with time and family and later on going back to school online became a little intimidating. When my parents died I then decided to pursue my dream of obtaining my APN. I have been blessed to have good instructors and classmates and I'm getting comfortable with school. It is a pleasure to meet everyone and good luck with class. Rochelle Elayda 4/26/2016 9:49:02 PM Discussion part 1 Allergic rhinitis Epidemiology: Allergic rhinitis is a common chronic disease with a prevalence between five and twenty-two percent in the United States (Khan, 2014). Many patients who have asthma also have allergic rhinitis. Rhinitis is most common in patients ages 15-25, and it affects more boys than girls (Batt, 2014). Allergic rhinitis is usually diagnosed before asthma and sensitization occurs at a very young age when the immune system is still immature (Batt, 2014). Symptoms include sneezing, itching, nasal irritation, and rhinorrhea. The symptoms occur when the patient breathes in allergens such as pollen, dust, food, and pet dander. Pathophysiology: When the patient is exposed to an allergen, the allergen-specific T cells is activated and causes the production of allergen-specific IgE (Batt, 2014). The IgE binds to receptors on mast cells and basophils. The allergen causes cell degranulation and releases mediators such as histamine, leukotrienes, and prostaglandins which causes the symptoms associated with allergic rhinitis (Batt, 2014). Argument: I think that John could be suffering from allergic rhinitis. With his history of asthma and pollen allergy as well as his symptoms of sneezing and nasal congestion, allergic rhinitis would be a perfect fit. Rhinosinusitis Epidemiology: Rhinosinusitis is the inflammation of the paranasal sinuses and nasal mucosa. About 31 million people are affected by sinusitis in the United States and is the fifth most common diagnosis in which antibiotics are prescribed (Shoup, 2011). About $3-$5 billion dollars of healthcare costs are due to patients with sinusitis. Pathophysiology: Rhinosinusitis is either acute or chronic. Acute rhinosinusitis can be either bacterial or viral. Viral rhinosinusitis is caused by exposure to viruses such as the rhinovirus, influenza A and B, parainfluenza, respiratory syncytial virus, adenovirus, and enterovirus (Shoup, 2011). When viruses enter the nasal passage, they attach to cell walls and activate several inflammatory pathways which causes an excess of turbinate vasculature, intercellular leakage, and seromucinous discharge (Shoup, 2011). Acute bacterial rhinosinusitis is commonly caused by Streptococcus pneumonia, Haemophilus influenzaie, Moraxella catarrhalis, and Stapholocoous aureus (Shoup, 2011). Chronic rhinosinusitis is caused by infection, allergies, genetics, or systemic disorders. The inflammatory cells that are triggered are eosinophils (Shoup, 2011). Argument: Symptoms of rhinosinusitis are cough, sneezing, rhinorrhea, nasal congestion, facial pain or pressure headache, and sore throat (Shoup, 2011). John has some of these symptoms but does not have a headache or facial pain which is a significant feature of rhinosinusitis. There is really no connection between rhinosinusitis and asthma or allergies to pollen. Rochelle Reference: Batt, R. (2014). Treatment of seasonal allergic rhinitis and impact on the adolescent. Nurse Prescribing, 12(3), 120-126. Retrieved from uid=;article=NP_12_3_120_126 Kahn, D. (2014). Allergic rhinitis and asthma: epidemiology and common pathophysiology. Allergy and Asthma Proceedings, 35, 357- 361. doi: 10.2500/aap.2014.35.3794 Shoup, J. (2011). Management of adult rhinosinusitis. The Nurse Practitioner, 36(11), 23-26. Retrieved from Rochelle Elayda reply to Rochelle Elayda 5/2/2016 4:32:42 PM RE: Discussion part 1 Continuation of original post: The Common Cold (Rhinovirus Infection): The common cold was discovered in 1956 by Dr. Winston Price where he was able to isolate the rhinovirus (Kennedy, Turner, Braciale, Heymann, & Borish, 2012). Adults experience two to three colds per year and children experience an average of eight to twelve per year. The virus affects the upper and lower airways. There is no cure for the common cold, but palliative relief help with symptoms. The common cold is largely responsible to loss of productivity, high healthcare costs, and triggering other illnesses (Witek, Ramsey, Carr, & Riker, 2014). Pathophysiology: The rhinovirus, which is the main virus that causes symptoms of the common cold, is a single-stranded non-enveloped RNA virus that has over 100 serotypes (Kennedy et al., 2012). When the RV enters the cell, the viral genome is translated into a polyprotein, which goes through a process called proteolytic cleavage which produces the structural and non-structural gene products (Kennedy et al., 2012). Argument: Symptoms of the common cold are sneezing, headache, malaise, chilliness, nasal discharge, nasal obstruction, sore throat, and cough. Although this diagnosis could be a possibility, John does not have many of those symptoms and does not feel malaise. Seasonal allergy: Epidemiology: Allergies affect approximately 15-20 percent of the population and has increased dramatically in the last 20-30 years. It is a huge hindrance for those affected by it. The most common cause of allergy symptoms is pollen, molds, and fungi(Middleton, 2016). Pathophysiology: When an allergen enters the body and invades the immune system, T helper cells and their mediators begin to respond by attacking this invader (Middleton, 2016). Antigen-presenting cells detect the allergen and then the allergen is absorbed, processed, and displayed on its surface. The invaded antigen-presenting cell migrates to the T-lymphocyte which stimulates the B-cell to produce the antibody, IgE. The IgE attaches itself on the surfaces of mast cells causing an inflammatory mediator such as histamine (Middleton, 2016). Argument: John is allergic to pollen which could trigger the symptoms described in the scenario. Seasonal Influenza: Epidemiology: Seasonal outbreaks for influenza in the United States occurs in the winter months. Globally, this illness has caused about half a million deaths each year (Goodband, Oakley, Rayner, Toms, & Brostoff, 2014). Influenza causes approximately 7.6 million working days a year (Goodband et al., 2014). One of the most important steps in the prevention of influenza is vaccination. Despite the well-known benefits of vaccination, many people continue to refuse to get vaccinated. Pathophysiology: The influenza virus is an RNA virus which is surrounded by a viral envelope containing glycoproteins (Goodband et al., 2014). Because this is an RNA virus (and not a DNA virus), the influenza genome is susceptible to spontaneous genetic mutations. These mutations may effect the genes that encode the H and N antibodybinding sites which in turn reduce the binding of existing antibodies. New viral strains tend to spread more rapidly. Argument: Although the influenza virus causes the symptoms that John currently has, this would be the last diagnosis I feel he would have. The flu causes fever, malaise, and body aches. John is still playing football, and if he had the flu, he would not feel well enough to play. Reference: Goodband, A., Oakley, S., Rayner, J., Toms, J., & Brostoff, J. (2014). Influenza: disease, epidemiology, and the importance of vaccination uptake by healthcare workers. Primary Health Care, 24(7), 33-38. Retrieved from Kennedy, J., Turner, R., Braciale, T., Heymann, P., & Borish, L. (2012). Pathogenesis of rhinovirus infection. Current Opinion in Virology, 2(3), 287-293. Retrieved from Middleton, J. (2016). The pathophysiology of allergic responses. Nursing Times. Retrieved from Rechel DelAntar 5/1/2016 2:35:58 PM Differential Diagnoses HDeiflfleor epnrotifaels Dsoiar gannods eCslass, s n e e z in g ,A i tccahsye eoyfe as 1a9n dy enaars aoll dc ocnoglleesgteio Fno wotibtha lsl ypmlapyteorm Jos hwno, r sweinthin g at night with a history of asthma, allergies to pollen and eczema. Vital signs appear normal except for a low grade fever of 100F. another teammate is experiencing the same signs and sym pAtnodm asl,t hito ugh cdoonetsi nnuootu ssa ya nwdh deind ibt ohtahs p slatayretresd ,e xapree rtiheen cseydm tphteo msysm opnt oamnds aotf ft ohre same tdiimffeer oern toianle d aiaftgenro tshees oatrhee:r. In the case of our patient, 5 possible 1. Rhinovirus = Commonly known as the common colds. Incubation apnerdi osdy misp utsoumasll yw 1o2u-ld7 2b eh onuarssa la dnids cmhaaryg lea,s nt a7s-a1l1 c doanygse sotrio lno,n gsneer.e zSiniggn s iptrcehsys ueryee.s ,I fne vseorm (et ycpaisceasll,y Rlohwin ogvrairdues) m, haeya edxaaccheer baantde faanci aals athnmd ae aart tack. ETnhgea gReVm weinllt i noffe rcetc tehpet oerpsi tchaeulisuems cinytdoukciinneg raens pinonnasete, wimhmichu nder irveessp onse. rneesuptoronpshe,il trheec rHuuitmmoernatl mimamniufenset esdy sbtye mne aucttriovpahteils l aBd ecenl lds iswcihtha rsgeerso.- In sTpraencisfmic iIsgsAio na nisd tIhgrGo uagnht ibdorodpielest (sKpernanye odry d, iJr.e, cet tc aoln.,t a2c0t1 a2n)d. t he tohreg asnaimsme csaignn sb ea nidde snytimfiepdto tmhrso oufg hth ais ndaisseaal ssew aabn.d cTohuel dp aetaiesinlyt pbree sents isnhfaercitnegd sbpyo rtthsi se vqiuriupsm tehnrot uwgihth c hoinst atecat mwmitha theiss. f r iends and specially 2. RSV/Respiratory Syncytial Virus = is a respiratory virus that infects the lmunildg sc oalndd l ibkree asythminpgt opmasss aangde sr eacnodv einr sh iena 1lt-h2y wpeeeokpsle a ins dm aaltnhifoeusgtehd i ta s a foocrc uDriss emasoes tClyo nint rcohl ialdnrde nP,r eitv ceannti ooncc, u2r0 i1n4 d).if f eSryemnpt taogme sg rraonugpisn g(C feronmte rs cvoenryg emstilido nt,o rluifnen tyh rneoastee,n mingild. Tcyopuigcha l ainnidt ialol wsy gmrapdtoem fesv aerre. n Tahsael RSV eVnirtuesr sis t hsep rbeoaddy w thheronu agnh itnhfee cnteodse p, eorrs omno cuotuhg ahnsd a vnedr ys noefteezne st.h eT heyee vsi rus pwahtehno gpeenoepsleis woifp teh itsh ediirs eeaysees ifsr onmot dfurollpyl ektn sopwrna yb uort tdhiree cvtir cuosn atattcatc. k sT hthee rceasupsieras ttohrey stryemep ctaoumssin wg hinefrleaimn mthaet ihoons. tT cheell irneflcaomgnmizaetso rtyh ere vsipruosn saen d cseelclrse ftreosm in tfhlaem pmeraiptohreyr yc yatnodk insiensc ea nitd i sin s tehlfe- lpimroitciensgs, dpraatiweinntgs irmeqmuuirnee snuapsaplo srtwivaeb cfaorre R (eAsmpieraritcoar yL upnagn eAl.s s Tochiiast cioonu,l d2 0b1e6 a) .l i kDeilayg dnioasgisn oiss itsh aros uhgeh icso nextahcibteitdin tgh es odmisee aosfe t hfreo msig onnse o of ft hheis dtiesaemas em eaxteces.p t A flotrh ocuoguhg hh ea nisd not tehxipse cough, he may just be starting with the disease process at 3. Acute Bacterial rhinosinusitis = This is characterized by the ioncfclaumrsm waitthioonu itn r hthinei tliisn,i nrhg inoof stihneu spiatirsa nisa tshael spinreufseersre. dS itnecrem s. in Suysmitipst roamresl y ipnocslut dnea snaal sdarli pco snegtes sitnio. n I,t fiesv sepr,r enaads athl rdoruipg,h f aateigrouseo al nadn dc oduirgehc tl actoenr toanct .a s Tdhevee eloaprl ys esctoangdea orfy sbinauctseitriisa li si nvfiercatl iohnosw geveenre raa lslym caallu nsuemd bbeyr a oefr opbaitcie nts ibnafcetcetrioian. aPnadti eisn tn iomt msturonneg s eynstoeumgh h taos fbigehetn ac osmecpornodm oispepdo rftruonmis tthice first organism. The symptoms are similar to the one experienced except that it is unclear how long has the patient had these s ybmy pJtoohmn s teht aatl .m, 2a0y 1s2u) that this is indeed a secondary infection (Kennedy, J., 4. Influenza = Influenza is a respiratory infection caused by the Influenza tvhireu sv.i rAulst hhoauvgeh b iet eisn liadregnetliyfi ecda tseugcohr izaesd t haes HA1, NB1 a nandd C H, 3nNew2 tshuabtt yhpaevse of cSaigunsse da nmdo srytamliptyt oimn sth ien cpluodpeu lasotiroen t(hCroeantt,e rnsa fsoarl Ddiisscehaasreg Ce,o nmtyroall,g 2ia0, 1r6e)d. saynmd pwtaotmersy. eTyreasn,s wmeisaskinones iss, tfhervoeurg cho uaegrho asonld o or tbhye rc roenstpaicrta twoirtyh saliva or tortahcetr arneds ptihraet ovirrya ls erecprelitciaotnios.n cTohme bviinruesd awtittahc himedm iutsneel fr teos pthone sree stop iratory itnhfeescet ioanre l evairduss etos ,t thhee dye hsatrvuec tai osne gamnde nlotessd ogfe cneolmls ein, wthheic lhin cinagu.s e As ltthhoeumg h tcoo urladp ibdely a e rveoalsvoen c afours itnhge apna teiepnidt etmo ibce ( Zexapmebrioenn,c Min.g, t2h0e1 6si)g. n aTnhde Flu smyymaplgtioam dse shpei ties hexahviinbigt inlogw h gorwaedvee fre, vheer .has not been complaining of any 5. Allergic Rhinitis (Hay fever) = This an allergic reaction triggered by onuastdaol ocro npgoellsetniosn a,n idtc hmyo eldyse,s s amnodk sen peoelzluintigo na nadn dn os tfreovnegr .s mIte allfsf e cctasu sailnl g abgy easn a onvde uranclitkivee v iimraml iunnfeec stiyosntse,m th wehy oa rmei sntoatk ceosn dtuasgtio ours p. oTlhleeny faorre g cearumsse aanntdi baotdtaiecsk sb itnhde mto. r e Uceppotno resx pino sthuere m toa stth ece alllsle orgf ethne s preescpifiirca tIogrEy mucosa. aWllheergne tnh e r easlluelrtginegn iins ianchtiavlaetdi oang aoifn t,h teh ec eIlgl Ea nadn ttihbeo dsiyems pbtinomd sw iotfh htahye faellveerrg i(cD rehSinhiatizso m, Ra.y bane ds iKmeimlarp ,b Su.t, J2o0h1n4 i)s. e Txhheib istiignngs l oawnd g sraydmep fteovmesr of which is not a typical sign for an allergic reaction. ARmefeerreicnacne sL:ung Association. (2016). RSV Symptoms, Causes and Risk Factors.h t Rtpe:t/r/iwevwewd .fluronmg. org/lung-health-and-diseases/lung-disease- l o o k u p / rcsavu/sresvs--mml.s- SCyenncteyrtsia fl oVri rDuiss eIansfeec C and Prevention. (2014). Respiratory C e n t e r s Rfeotrr Dieivseeda sfero Cmo nhttrtopl:. /(/2w0w1w6).c. d Ive/nrzsav /(.Flu). Retrieved from hDtetSp:h/a/zwow, wR.. cadncd.g Koevm/flpu,/ .S. (2014). Pathogenesis of Allergic rhinitis. R e t r ie v e dh tftrpo:m// Zambon, M. (2016). Epidemiology and Pathogenesis Journal of Antimicrobial of Influenza. Chemotherapy. 71(5), 3-9. Lorna Durfee 5/1/2016 3:45:14 PM Discussion Part 1 - Differentials Jnoahsanl ics oan g1e9s-ytieoanr -thoaldt wcoolrlesegnes f oaot tnbiaglhl tp. lHayee srt awtehso tphraets heen thsa ws iath h sinsteoerzyi nogf, aistcthhmy aey, eesc,z aemnda saynmd patlolemrsg.i eHsi sto v iptoalllse anr. eT BhePr e1 1is0 a/7ls0o, Po n8e4 o, tRh e1r8 p, eTr s1o0n0 oFn. the football team that has similar FWorri teea cah d dififseeraesnet iianlc oluf daet ilneafosrt mfivaeti o(5n) apboosusitb tlhe ei teepmids efmroimol otghye, mpaotsht olipkheylys itoolo lgesys a lnikde ly. bprrieesfelny taartigoune. why this disease fits the presentation and why it might not fit the Dr. Brown and Class: cSounbgjeecsttiivoenl yw, othrsee npiantige natt pnrigeshet.n tTs hweirteh ias hai hstiostroyr oyf o sfn aesetzhimnga,, iatlclheyrg eieyse st,o a pnodl lneans aanl d encozremmaal.. HOeb jmecetnivtieolnye, dh eth saht otwhesr ea nis e alenvoathteedr tceomntpaecrta otunr eh,i sb ufot oottbhaelrl vteitaaml stihgants h aapsp seiamr itloa rb e symptoms and is having an exacerbation of allergy symptoms. The differentials are as follows: aDllieffregriecn styimalp #t1o:mAs.l lWerhgeicn rrehsienaitricsh–in gB iencfaoursmea Jtoiohnn rheagsa radllienrgg iaelsle, rhgei cc orhuilndi tbise aenxdh itbhieti ng pmaothsto cpohmysmioolong Iyg,E S-mine adnidat eTdo gdiiasse a(s2e0s1. 1 T) hinef oreramc ttihoen roecacduerrs t fhraotm al ilnerhgailcin rgh iannit iasl liesr goenne aonf dth e ismetms tuhneo sltoaggiec aflo ar nad t ybpioec 1h ehmypicearls.e nPsoitlilveint yc arnea scetti oonf.f Tanh ea lrleesruglitcs raeraec etivoenn tbse tchaauts aer teh beo th ipnatroti tchlees t iosfs uthees aolfl ethrgee nno asree ( iTnoggeisatse d& a nSdin a, r2e0 i1n1c,o prp. o1r0a8te).d into the nasal mucus and then sSwenaslliotiwza utipo nth hea aplpleerngse bne acnadu steh ethne b arneatikg ethne-pmr edsoewntnin ign tcoe lples p(tAidPeCs st)h,a wt mhiochv ea rine tdoe lnydmriptihc , lnyomdepsh.o cTyhtee sp orers Ten ctealtliso.n Tohf eth deesned preitpicti dceesll sis s teot uthpe an noet tyweot rskp eincsifiidce e tphiet oeppei tCheDli4u mT and the trhesep eipraitthoeryli ummu cwoistah arnhdin nitaiss.a lA mlsuoc, oostah.e rD seignndarlisti cth caet lalsf faencdt DTC cse lalsn din Tcr ceealsles oinnc tlhued es urface of lpirgoasntdag (lTanodgiinas E & aSnind, l2y0m1p1h, opp. o1i0e8ti)n. from the epithelial cells and this, in turn, expresses TTrheeg rse cgaunla atolsroy iTn dcueclles a(pTorepgtocseisl.l s ) M suopspt raelsles rtghiec ipmamtieunntes creasnp hoanvsee sa tlhlerroguegnh- scpyetcoikfiicn eIsL.- 4 edfefveecltoopr .T T cheelrles ,i sIL s-o1m0 eT irn1d cicealltsio, na ntdh aTt rreeggsu.l a tTohrye bTa claenllcse a oref tnhoets we ocarkni ndgec aindde iafr ea ldleerfgeyc twiviell in allergic rhinitis (Togias & Sin, 2011, p. 108). eTxhpereBs slyinmgp mhoemcyoterys sBy-nctehlel sciyzteo IkginEe fsr owmil ld tihreenct iporno dauncde r celgounlaalt ieoxnp oafn sthioen c. y Atonkointheesr. sIiggEn- cboet-wsiemeunl alitgioann du rCgDes4 B0 -ocne ltlh aec Tti vcaetlilo ann adn Cd Dre4c0o monb itnhaet iBo nc eflolr p prroodduucceisn gco I-gsEti.m Tuhlaet (ioFnc.ε R TIh) is interactions on the basophils and the mast cells produce an allergic reaction, and this is at 2 the cellular level (Togias & Sin, 2011, p. 108). This patient may also rhinitis and vasomotor rhinitis instead. Consideration must include a lhlearvgey n aonnda lilnefregcitci on (cTurorgeinatsl y& e xShinib, i2ti0n1g1. p. 111). Allergic rhinitis fits the presentation of the symptoms he is IDniffefcetrieonutsi aDl i#se 2a:s eSse (a2s0o1n6a)l taelllle ursg yth taot ppoolllleenn i–s a T mhaej oNra ttriiogngaelr I fnosrt iatullteer goife As.l lUersguya lalnyd kDnisoewanse isn r leafyemrsa tno’ sit taesr m“sse aass ohnaayl faelvleerrg, itch erh Ninaittiios.n”a lT Ihnes tsittuatteis toifc sA sltlaetreg yth aant dp oInllfeenc tailoluersg y saefftes cotfsf 7 a np earlcleerngt iocf r aedacutlitosn a nthdr o9u pgehr cthene ti mofm chuinled rseyns tleivmin tgo iann t ahlel eUrgneitne dth Satt amteasy. sTeheem b ody hhaarsm solemsse tpoo slloemn ea lbleurtg fyo rt hoatht earrsis, eist cina nt hcea ufaslel .m Hajios rs pyrmopbtloemmss. c oItu aldp pbeea rfsro tmha tw teheisd sp athtiaetn at re pmraenseyn pt eionp tlhee. fIafl lh oer o snolmy eh aost hseyrm apllteormgesn f osru cah p aesr imodo,l pde. r Rhaapgsw heee dis caalulesregsi cp rtoob tlheem pso flolern s in tIhnefe acitri oaut st hDe itsiemasee. s T, 2h0e1se6 )c.a nT oc aduestee ramllienreg yif s hyem hpatso mans .a (lNleargtiyo ntoa lc Ienrstatiitnu taen otifg Aenlsle hrge yw ainlld anleleedrg tyo abpep teeasrtse dto t ofi tc othnef iprmre.s e Inf tnatoito, nt haesn w heel lc. ould have some other condition. Seasonal rDhiifnfoersiennutsiaitli s# i s3 :i n Sflianmums iantifoenct oiofn th -e A mriuncgo saan din C thhaen n (a2s0al1 p2a) sesxapgleasi.n Tthhaet aAcmuteer isciannu sitis or eAitchaedre bmayc toefr iOalt oolra vryirnagl o(Alorgiyn gd e&fi nCehsa rnh, i2n0o1si1n,u ps.i t1is0 5b7a)s.e dT ohne dauutrhaotirosn i nafnodr mis ucos nthsiadte sriendu sitis cnaons er easnudl tn farsoaml pvaisrsuasgees sa lsesaodcsia ttoe de dweimtha twheh iccohm imn tounr nc ocladu. s eTsh oeb lsintriuncgt ioofn t ohfe tmheu csoinsuas o afn tdh ei n thhaei ros)s tiinas. i dAel sthoe, tnhoes be,a cwtehriicahl ahnadv ev tihrael aibnifleictyti oton st rcaanns pimorpt emduec tuhse. a Bcteiocanu osfe tthhee rcei liisa a(nli ttle roebdsutrcuticotino no,f iot xsylogwens tdeonwsino nth ien mthuec suisn utrsa ncaspvoitrite;s t hrees sueltcsr e(Atiorinnsg b &ec oCmhaen s,t 2ag0n1a1t,e p, .a 1n0d5 7). This condition allows for the proliferation of virus and bacteria. SCtoamphmyolonc oorcgcaunsi Asmusre iuns a, cauntde Hsianeumsiotipsh airleu st hinofsleu eonf zSat raesp wtoeclol cacsu Ms ponraexuemlloan ciaa,t arrhal. Viruses acdoemnmovoinrulys a(Assroicniga t&ed C whiathn ,v 2i0ra1l1 s,i npu. s1i0ti5s8 a)r.e;B rehcianuosvei rtuhse,r pe airsa ninof lwuaeyn zoaf aknndo winifnluge hnozwa alnodn g tthhiiss , hwase bmeuesnt gsoeein tgh aotn t,h iet issy hmaprdto tmo st eblel cwohmeeth wero trhseis a ifst ear psreovleonn gtoe d1 0in dfeacytsi oonr. l aTsot fdoira glonnogseer than 10 days (Aring & Chan, 2011, p. 1058). JDoihffne rheans tbiaele n# n4e: aCr othmatm aothnl ectoel dan -d B inec aanu seen