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Wang X, Luo JN, Wu XY, Zhang QX, Wu B. Study of liver cirrhosis over twenty consecutive years in adults in Southern China. World J Hepatol 2023; 15:1294-1306. [PMID: 38223413 PMCID: PMC10784809 DOI: 10.4254/wjh.v15.i12.1294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/07/2023] [Accepted: 11/24/2023] [Indexed: 12/25/2023] Open
Abstract
BACKGROUND Liver cirrhosis (LC) is a prevalent and severe disease in China. The burden of LC is changing with widespread vaccination of hepatitis B virus (HBV) and antiviral therapy. However, the recent transition in etiologies and clinical features of LC cases requiring hospitalization is unclear. AIM To identify the transition in etiologies and clinical characteristics of hospitalized LC patients in Southern China. METHODS In this retrospective, cross-sectional study we included LC inpatients admitted between January 2001 and December 2020. Medical data indicating etiological diagnosis and LC complications, and demographic, laboratory, and imaging data were collected from our hospital-based dataset. The etiologies of LC were mainly determined according to the discharge diagnosis, and upper gastrointestinal bleeding, ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, hepatocellular carcinoma (HCC), portal vein thrombosis, hepatorenal syndrome, and acute-on-chronic liver failure (ACLF) were considered LC-related complications in our study. Changing trends in the etiologies and clinical characteristics were investigated using logistic regression, and temporal trends in proportions of separated years were investigated using the Cochran-Armitage test. In-hospital prognosis and risk factors associated with in-hospital mortality were also investigated. RESULTS A total of 33143 patients were included in the study [mean (SD) age, 51.7 (11.9) years], and 82.2% were males. The mean age of the study population increased from 51.0 years in 2001-2010 to 52.0 years in 2011-2020 (P < 0.001), and the proportion of female patients increased from 16.7% in 2001-2010 to 18.2% in 2011-2020 (P = 0.003). LC patients in the decompensated stage at diagnosis decreased from 68.1% in 2001-2010 to 64.6% in 2011-2020 (P < 0.001), and the median score of model for end-stage liver disease also decreased from 14.0 to 11.0 (P < 0.001). HBV remained the major etiology of LC (75.0%) and the dominant cause of viral hepatitis-LC (94.5%) during the study period. However, the proportion of HBV-LC decreased from 82.4% in 2001-2005 to 74.2% in 2016-2020, and the proportion of viral hepatitis-LC decreased from 85.2% in 2001-2005 to 78.1% in 2016-2020 (both P for trend < 0.001). Meanwhile, the proportions of LC caused by alcoholic liver disease, autoimmune hepatitis and mixed etiology increased by 2.5%, 0.8% and 4.5%, respectively (all P for trend < 0.001). In-hospital mortality was stable at 1.0% in 2011-2020, whereas HCC and ACLF manifested the highest increases in prevalence among all LC complications (35.8% to 41.0% and 5.7% to 12.4%, respectively) and were associated with 6-fold and 4-fold increased risks of mortality (odds ratios: 6.03 and 4.22, respectively). CONCLUSION LC inpatients have experienced changes in age distribution and etiologies of cirrhosis over the last 20 years in Southern China. HCC and ACLF are associated with the highest risk of in-hospital mortality among LC complications.
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Affiliation(s)
- Xing Wang
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China
| | - Jin-Ni Luo
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China
| | - Xiao-Ying Wu
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China
| | - Qi-Xian Zhang
- Patient Case Management Division, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China
| | - Bin Wu
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China.
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Lv Y, Fan D, Han G. Transjugular intrahepatic portosystemic shunt for portal hypertension: 30 years experience from China. Liver Int 2023; 43:18-33. [PMID: 35593016 DOI: 10.1111/liv.15313] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 04/05/2022] [Accepted: 05/15/2022] [Indexed: 01/04/2023]
Abstract
Liver diseases are a major cause of illness and death worldwide. In China, liver diseases, primarily viral hepatitis, affect approximately 300 million people, thus having a major impact on the global burden of liver diseases. Portal hypertension is the most severe complication of chronic liver diseases, including ascites, hepatic encephalopathy and bleeding from gastroesophageal varices. Transjugular intrahepatic portosystemic shunt (TIPS) represents a very effective treatment of these complications. Since its introduction 30 years ago in China, the use of TIPS has evolved and has played an increasingly important role in the management of the complications of portal hypertension. This review will focus on the history, current application and management of complications of TIPS in China.
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Affiliation(s)
- Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, China.,Military Medical Innovation Center, Fourth Military Medical University, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, China
| | - Guohong Han
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, China
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Milovanovic T, Lugonja S, Pantic I, Miltenovic S, Vlaisavljevic Z, Mardani A. Cirrhosis Due to Alcohol-Related Liver Disease Hospitalizations in Belgrade, Serbia: A 10-Year Retrospective. IRANIAN JOURNAL OF PUBLIC HEALTH 2022; 51:2271-2280. [PMID: 36415809 PMCID: PMC9647601 DOI: 10.18502/ijph.v51i10.10985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/24/2021] [Indexed: 08/29/2023]
Abstract
BACKGROUND Cirrhosis due to alcohol-related liver disease (ALD cirrhosis) is a significant burden to health systems worldwide. We aimed to determine the trends in hospitalization frequency due to ALD cirrhosis and to analyze their characteristics. METHODS This cross-sectional study used data from the Institute of Public Health of Belgrade database, and included all hospitalization reports which contained code K70.3 (Cirrhosis hepatis alcoholica) as the primary diagnosis, including re-hospitalizations, on the territory of Belgrade, between January 2009 and December 2018. RESULTS A total of 4644 patients with ALD cirrhosis were hospitalized (male: 4154, 89.45%), with a mean age of 58.83±10.02 years. During the 2009-2018 decade, no difference in the number of ALD cirrhosis hospitalizations in subsequent years was observed. Men more commonly developed esophageal and gastric varices with bleeding compared to women (P=0.037), while women developed acute-on-chronic liver failure (ACLF) almost two-times more often compared to men (P<0.001). Patients with hepatocellular carcinoma were significantly older (P<0.001), while those who developed ascites and splenomegaly were significantly younger compared to those who did not (P<0.001 and P=0.04, respectively). Altogether, complications of portal hypertension were registered and reported with very low frequency, and therefore do not represent actual frequencies of these conditions. The median duration of hospital stay was 9 days (range 0-243). Patients in whom lethal outcome occurred during the hospitalization were significantly older, and more commonly developed chronic renal failure. CONCLUSION These data offer an important insight into the ALD cirrhosis-related hospitalizations while drawing attention to inadequate coding as an important public health issue at the same time.
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Affiliation(s)
- Tamara Milovanovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic of Gastroenterology and Hepatology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Sofija Lugonja
- General Hospital “DjordjeJoanovic”, Department of Internal Medicine, Division of gastroenterology, Zrenjanin, Serbia
| | - Ivana Pantic
- Clinic of Gastroenterology and Hepatology, University Clinical Center of Serbia, Belgrade, Serbia
| | | | - Zeljko Vlaisavljevic
- Clinic of Gastroenterology and Hepatology, University Clinical Center of Serbia, Belgrade, Serbia
- Medical School of Vocational Studies Medika, Belgrade, Serbia
| | - Abbas Mardani
- Nursing Care Research Center, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
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Liu B, Cheng M, Lang L, Li L, Si Y, Wang G. Autologous Bone Marrow Cell Infusion for the Treatment of Decompensated Liver Cirrhosis Patients With Type 2 Diabetes Mellitus. Front Physiol 2021; 12:730797. [PMID: 35035357 PMCID: PMC8753408 DOI: 10.3389/fphys.2021.730797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 10/26/2021] [Indexed: 11/13/2022] Open
Abstract
This study aimed to indicate whether autologous bone marrow cell infusion (ABMI) via the right omental vein (ROV) could have a regulatory effect on decompensated liver cirrhosis (DLC) patients with type 2 diabetes mellitus (T2DM). For this purpose, 24 DLC patients with T2DM were divided into observation group (n=14) and control group (n=10). Patients in the observation group were given ABMI through the ROV and right omental artery (ROA), and cases in the control group received ABMI through the ROV. At 1, 3, 6, and 12months after ABMI, it was revealed that the prothrombin time, the total bilirubin levels, and the amount of ascites were significantly lower, while the serum albumin levels in the two groups were markedly higher compared with those before ABMI (p<0.01), and there was no significant difference between the two groups at each time point (p>0.05). The fasting blood glucose and glycosylated hemoglobin levels at 6 and 12months after ABMI in the two groups significantly decreased compared with those before ABMI (p<0.05 or p<0.01), while the decreased levels in the observation group were more obvious than those in the control group at each time point (p<0.01). The amount of insulin in the observation group at 3, 6, and 12months after ABMI was significantly less than that before ABMI in the control group (p<0.01). In summary, ABMI showed a significant therapeutic efficacy for DLC patients with T2DM through ROV and ROA.
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Affiliation(s)
- Baochi Liu
- Department of Surgery, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
- *Correspondence: Baochi Liu,
| | - Mingrong Cheng
- Department of Anorectal Surgery, Panzhou People’s Hospital, Guizhou, China
- Shanghai New Hongqiao International Medical Center, Shanghai, China
| | - Lin Lang
- Department of General Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lei Li
- Department of Surgery, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | - Yanhui Si
- Department of Surgery, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | - Guangmian Wang
- Shanghai New Hongqiao International Medical Center, Shanghai, China
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Risk factors for the concomitant occurrence of alcoholic chronic pancreatitis and alcoholic liver cirrhosis: a 10-years cohort study at a tertiary hospital in China. Eur J Gastroenterol Hepatol 2020; 32:1229-1234. [PMID: 31851081 DOI: 10.1097/meg.0000000000001643] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Concomitant occurrence of alcoholic chronic pancreatitis (ACP) and alcoholic liver cirrhosis (ALC) is rare with few reported cases. The present study aimed to identify the potential risk factors of chronic pancreatitis (CP) and liver cirrhosis (LC) in ALC patients and ACP patients, respectively. METHODS A retrospective analysis was performed on 536 patients with CP and 647 ALC patients without CP (Group A). Among the 536 CP patients, 213 ACP cases were divided into two groups: ACP with LC (Group B, n = 52) and ACP without LC (Group C, n = 161). A comparison between Group A and B was carried out to identify the potential risk factors of CP in ALC patients, while Group B and C were compared to determine the independent risk factors of LC in ACP patients. RESULTS Concomitant occurrence of ACP and ALC accounted for 24.4% (52/213) in this cohort. Significant risk factors for CP in ALC patients included smoking [odds ratio (OR), 2.557; 95% confidence interval (CI): 1.531-5.489; P = 0.003] and multiple bouts of acute pancreatitis (OR, 4.813; 95% CI: 3.625-12.971; P < 0.001). Hepatitis B virus (HBV) infection (OR, 4.237; 95% CI: 1.742-7.629; P = 0.012) was the only independent risk factor associated with LC in ACP patients. CONCLUSION HBV infection exacerbated liver damage in ACP patients. Alcoholic patients who smoked and suffered from ongoing bouts of acute pancreatitis are prone to develop CP.
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Sarin SK, Kumar M, Eslam M, George J, Al Mahtab M, Akbar SMF, Jia J, Tian Q, Aggarwal R, Muljono DH, Omata M, Ooka Y, Han KH, Lee HW, Jafri W, Butt AS, Chong CH, Lim SG, Pwu RF, Chen DS. Liver diseases in the Asia-Pacific region: a Lancet Gastroenterology & Hepatology Commission. Lancet Gastroenterol Hepatol 2020; 5:167-228. [PMID: 31852635 PMCID: PMC7164809 DOI: 10.1016/s2468-1253(19)30342-5] [Citation(s) in RCA: 310] [Impact Index Per Article: 77.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 07/20/2019] [Accepted: 08/02/2019] [Indexed: 02/06/2023]
Abstract
The Asia-Pacific region is home to more than half of the global population and accounted for 62·6% of global deaths due to liver diseases in 2015. 54·3% of global deaths due to cirrhosis, 72·7% of global deaths due to hepatocellular carcinoma, and more than two-thirds of the global burden of acute viral hepatitis occurred in this region in 2015. Chronic hepatitis B virus (HBV) infection caused more than half of the deaths due to cirrhosis in the region, followed by alcohol consumption (20·8%), non-alcoholic fatty liver disease (NAFLD; 12·1%), and chronic infection with hepatitis C virus (HCV; 15·7%). In 2015, HBV accounted for about half the cases of hepatocellular carcinoma in the region. Preventive strategies for viral hepatitis-related liver disease include increasing access to clean drinking water and sanitation. HBV vaccination programmes for neonates have been implemented by all countries, although birth-dose coverage is extremely suboptimal in some. Availability of screening tests for blood and tissue, donor recall policies, and harm reduction strategies are in their initial stages in most countries. Many governments have put HBV and HCV drugs on their essential medicines lists and the availability of generic versions of these drugs has reduced costs. Efforts to eliminate viral hepatitis as a public health threat, together with the rapid increase in per-capita alcohol consumption in countries and the epidemic of obesity, are expected to change the spectrum of liver diseases in the Asia-Pacific region in the near future. The increasing burden of alcohol-related liver diseases can be contained through government policies to limit consumption and promote less harmful patterns of alcohol use, which are in place in some countries but need to be enforced more strictly. Steps are needed to control obesity and NAFLD, including policies to promote healthy lifestyles and regulate the food industry. Inadequate infrastructure and insufficient health-care personnel trained in liver diseases are issues that also need to be addressed in the Asia-Pacific region. The policy response of most governments to liver diseases has thus far been inadequate and poorly funded. There must be a renewed focus on prevention, early detection, timely referral, and research into the best means to introduce and improve health interventions to reduce the burden of liver diseases in the Asia-Pacific region.
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Affiliation(s)
- Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India.
| | - Manoj Kumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
| | - Mohammed Eslam
- Storr Liver Centre, The Westmead Institute for Medical Research, University of Sydney and Westmead Hospital, Westmead, Australia
| | - Jacob George
- Storr Liver Centre, The Westmead Institute for Medical Research, University of Sydney and Westmead Hospital, Westmead, Australia
| | - Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Sheikh M Fazle Akbar
- Department of Pathology, Ehime University Proteo-Science Center, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, Japan
| | - Jidong Jia
- Liver Research Center, Beijing Friendship Hospital, Capital Medial University, Beijing, China
| | - Qiuju Tian
- Liver Research Center, Beijing Friendship Hospital, Capital Medial University, Beijing, China
| | - Rakesh Aggarwal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | | | - Masao Omata
- Department of Gastroenterology, Yamanashi Central Hospital, Yamanashi, Japan; University of Tokyo, Tokyo, Japan
| | - Yoshihiko Ooka
- Department of Gastroenterology, Chiba University Hospital, Chiba, Japan
| | - Kwang-Hyub Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Hye Won Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Wasim Jafri
- Department of Medicine, Section of Gastroenterology, The Aga Khan University, Karachi, Pakistan
| | - Amna S Butt
- Department of Medicine, Section of Gastroenterology, The Aga Khan University, Karachi, Pakistan
| | - Chern H Chong
- Division of Gastroenterology & Hepatology, National University Health System, Singapore; Division of General Medicine, Woodlands Health Campus, Singapore
| | - Seng G Lim
- Division of Gastroenterology & Hepatology, National University Health System, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Raoh-Fang Pwu
- National Hepatitis C Program Office, Ministry of Health and Welfare, Taipei, Taiwan
| | - Ding-Shinn Chen
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan; Genomics Research Center, Academia Sinica, Taipei, Taiwan
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Missoum H, Alami M, Bachir F, Arji N, Bouyahya A, Rhajaoui M, El Aouad R, Bakri Y. Prevalence of autoimmune diseases and clinical significance of autoantibody profile: Data from National Institute of Hygiene in Rabat, Morocco. Hum Immunol 2019; 80:523-532. [PMID: 30807792 DOI: 10.1016/j.humimm.2019.02.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 02/15/2019] [Accepted: 02/22/2019] [Indexed: 12/19/2022]
Abstract
AIM The objective of this study was to explore the prevalence of various autoimmune diseases (AIDs) in a large cohort of patients and to characterize the autoantibody profile in the patients with and without AIDs to confirm the diagnosis and to refine the Moroccan databases. PATIENTS AND METHOD Retrospective study was conducted in the Laboratory of autoimmunity National Institute of Hygiene (NIH) of Rabat in Morocco. A total of 3182 consecutive Moroccan patients (2183 females and 999 males) whose sera were tested for 14 autoantibody profile between 2010 and 2016. RESULTS Only 944 (29.7%) patients were diagnosed with AIDs of those suspected. The prevalence of systemic lupus erythematosus (SLE), intestinal malabsorption (IM) and arthritis polyarthralgia (AP) were the highest (4.2, 4.1 and 4%), subsequently followed by rheumatoid arthritis (RA) (2.8%), cholestatic syndrome (CS) (1.8%), interstitial lung disease (ILD) (1.6%).In females IM, AP and SLE also showed the highest prevalence (5.4%, 5.3% and 4.9% respectively), while of male, SLE showed the highest prevalence (1.9%). The prevalence of ANA was increased in most patients with systemic especially in neuropathy (NP), hemolytic anemia (HA), primary Sjogren's syndrome (pSS), dermatomyositis (DM), thrombocytopenia (Tb), systemic sclerosis (SSc), ANCA-associated vasculitis (AAV), AP, Renal impairment (RI), SLE, and mixed connective tissue disease (MCTD). Anti-dsDNA antibodies were higher in SLE and ENA showed the highest titers in MCTD. Others are relatively specific for certain disease, such as anti β2GP1 for thrombosis syndrome, anti ANCA for primary sclerosing cholangitis (PSC), AAV, ILD and RI, anti CCP2 for RA, ILD and AP. the prevalence of anti AMA was higher in primary biliary cirrhosis (PBC), followed in CS, also, ANA have been identified in up to 25% of patients with primary biliary cirrhosis. The prevalence of anti-SMA was higher in PBC, treated patients for Chronic hepatitis C (HCV), and autoimmune hepatitis (AIH) and anti-PCA was higher in biermer anemia patients with vitamin B12 deficiency (BA/Def vit B12). The prevalence of IgA EMA, IgA tTG and IgA AGA were higher in patients IM and celiac disease (CD). The prevalence of anti thyroperoxidase (TPO) was significantly increased in the autoimmune thyroiditis (AIT). CONCLUSION Our study shows the diagnostic value of auto antibodies in AIDs. It would be interesting to carry out prospective studies on each pathology separately, in order to fill the classic vagaries of the retrospective study and objectively estimate the prevalence in different AIDs. These data on the prevalence of each autoimmune disease are valuable for the public health system.
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Affiliation(s)
- Hakima Missoum
- Laboratory of Human Pathologies Biology, Department of Biology, Faculty of Sciences, and Genomic Center of Human Pathologies, Faculty of Medicine and Pharmacy, Mohammed V University in Rabat, Morocco; Laboratory Autoimmunity, Department of Immunology, National Institute of Hygiene, Rabat, Morocco.
| | - Mohammed Alami
- Laboratory of Microbiology and Molecular Biology, Faculty of Science, Mohammed V University, Rabat, Morocco
| | | | - Naima Arji
- National Institute of Hygiene, Rabat, Morocco
| | - Abdelhakim Bouyahya
- Laboratory of Human Pathologies Biology, Department of Biology, Faculty of Sciences, and Genomic Center of Human Pathologies, Faculty of Medicine and Pharmacy, Mohammed V University in Rabat, Morocco
| | | | - Rajae El Aouad
- Hassan II Academy of Science and Technology Rabat, Morocco
| | - Youssef Bakri
- Laboratory of Human Pathologies Biology, Department of Biology, Faculty of Sciences, and Genomic Center of Human Pathologies, Faculty of Medicine and Pharmacy, Mohammed V University in Rabat, Morocco
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