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Jafree SR, Naveed A, Ahsan H, Burhan SK, Khan MA, Khawar A, Fischer F. Mental health and quality of life in patients with chronic liver disease: a single-center structural equation model. BMC Gastroenterol 2024; 24:193. [PMID: 38840079 PMCID: PMC11155103 DOI: 10.1186/s12876-024-03268-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 05/15/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND Chronic liver disease (CLD) is one of the leading disease burdens in Pakistan. Until now, there has only been limited focus in the country on providing health services through tertiary services in urban cities, whereas there is almost no research in Pakistan on the mental health and quality of life of CLD patients. This study aimed to understand which predictors influence the mental health and quality of life of CLD patients in order to advise better policy protection. METHODS Data was collected from CLD patients at the Pakistan Kidney and Liver Institute and Research Centre, Lahore, Pakistan. A total of 850 respondents were part of the final sample. The age of respondents ranged from 18 to 79 years and included the following diagnosis: (i) Chronic Viral Hepatitis (n = 271), (ii) Cirrhosis (n = 259), (iii) Hepatocellular Carcinoma (n = 193), and (iv) Non-viral Liver Disease (n = 127). RESULTS Mean results reveal that females as well as illiterate patients need more support for mental health and communication with their physician; whereas men need more support to develop coping strategies. Structural equation modelling results reveal that the severity of symptoms (β = 0.24, p < 0.001), coping strategies (β=-0.51, p < 0.001), and doctor communication (β=-0.35, p < 0.001) predict mental health. Quality of life is associated with the severity of symptoms (β=-0.36, p < 0.001), coping strategies (β = 0.26, p < 0.05), and doctor communication (β = 0.09, p < 0.05). CONCLUSIONS A 'bio-psycho-social-spiritual' model is recommended for Pakistan's CLD patients which includes the integration of social officers to provide support in four key areas to secure mental health and quality of life of patients.
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Affiliation(s)
- Sara Rizvi Jafree
- Department of Sociology, Forman Christian College University, Lahore, Pakistan
| | - Ammara Naveed
- Pakistan Kidney Liver Institute and Research Centre, Lahore, Pakistan
| | - Humna Ahsan
- Department of Economics, Forman Christian College University, Lahore, Pakistan
| | | | - Masha Asad Khan
- Academic Dean of Humanities and Social Sciences, Kinnaird College for Women, Lahore, Pakistan
| | - Amna Khawar
- Department of Psychology, Lahore College of Women University, Lahore, Pakistan
| | - Florian Fischer
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany.
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Nsibirwa SK, Aizire J, Mugerwa JN, Thomas DL, Ocama P, Kirk GD. The impact of HIV infection on clinical presentation and mortality among persons with hepatocellular carcinoma in Kampala, Uganda. BMC Infect Dis 2023; 23:216. [PMID: 37024807 PMCID: PMC10080890 DOI: 10.1186/s12879-023-08164-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 03/15/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND HIV infection is associated with more rapid progression of some comorbidities. This study assessed the impact of HIV-infection on the presentation and outcome of HCC. METHODS HCC patients attending the Mulago National Referral Hospital in Uganda were enrolled into a natural history study of HCC between March 2015 and February 2019. Standardized methods were used to collect clinical, ultrasound and laboratory data at enrolment. HCC cases were confirmed and enrolled based on a combination of clinical, ultrasound, tumor marker and pathology data. Follow-up contact was made at one, three, six, and twelve months post-enrolment to determine vital status. Symptoms and signs at diagnosis and subsequent survival were compared by HIV status. Kaplan Meier curves were used to assess HCC survival. RESULTS Of 441 persons with HCC, 383 (87.0%) died within 12 months following HCC diagnosis. The median (IQR) survival was 42 (20, 106) days. HIV infection was present in 79 (18%) cases. After adjusting for baseline demographic and clinical characteristics, HIV infection was associated with increased mortality but only among those with severe HIV-associated immunosuppression (CD4 count < 200 cells per cubic milliliter), aHR (95% C) = 2.12 (1.23-3.53), p = 0.004, and not among PLWH with ≥ 200 CD4 cells per cubic milliliter, aHR (95% C) = 1.15 (0.82-1.60), p = 0.417. CONCLUSION Among relatively young Ugandans, HCC is a devastating disease with rapid mortality that is especially rapid among people living with HIV(PLWH). HIV was associated with slightly higher mortality, notably among PLWH with lower CD4 cell counts. As a substantial majority of PLWH diagnosed with HCC were engaged in HIV care, further investigation should determine the effectiveness of incorporating screening and early identification of HCC among high-risk individuals into existing HIV care programs. Concurrent with growing access to curative localized treatment for HCC in sub-Saharan Africa, leveraging HIV care infrastructure affords opportunities for earlier HCC intervention.
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Affiliation(s)
- Sara K Nsibirwa
- HIV and HCC in Uganda (H²U) Consortium, Kampala, Uganda.
- Infectious Diseases Institute (IDI), Makerere University, Kampala, Uganda.
| | - Jim Aizire
- HIV and HCC in Uganda (H²U) Consortium, Kampala, Uganda
- Johns Hopkins University, Baltimore, MD, USA
| | | | - David L Thomas
- HIV and HCC in Uganda (H²U) Consortium, Kampala, Uganda
- Johns Hopkins University, Baltimore, MD, USA
| | - Ponsiano Ocama
- HIV and HCC in Uganda (H²U) Consortium, Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Gregory D Kirk
- HIV and HCC in Uganda (H²U) Consortium, Kampala, Uganda
- Johns Hopkins University, Baltimore, MD, USA
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Davwar PM, Okeke E, Duguru M, Nyam D, Bell K, Odeghe EA, Oyeleke G, Lesi OA, Singh R, Kim KY, Imade G, Akanmu AS, Sagay AS, Ogunsola FT, Peters MG, Roberts LR, Hou L, Murphy RL, Hawkins CA. Hepatocellular carcinoma presentation and prognosis among Nigerian adults with and without HIV. PLoS One 2023; 18:e0282539. [PMID: 36877687 PMCID: PMC9987777 DOI: 10.1371/journal.pone.0282539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 02/17/2023] [Indexed: 03/07/2023] Open
Abstract
INTRODUCTION Hepatocellular carcinoma (HCC) is an increasing cause of mortality in Nigeria among persons with HIV (PLH), as access to antiretroviral therapy (ART) improves. In this study we describe clinical, radiological, and laboratory characteristics in Nigerian adults with HCC, with and without HIV, and examine how HIV impacts survival. METHODS This prospective observational study was conducted between August 2018 and November 2021 at two Nigerian hospitals [Jos University Teaching Hospital (JUTH) and Lagos University Teaching Hospital (LUTH)]. Subjects ≥18 years with HCC diagnosed according to American Association for the Study of Liver Diseases (AASLD) criteria were included. Baseline characteristics were compared, and Kaplan-Meier curves were generated to estimate survival. RESULTS 213 subjects [177 (83%) without HIV and 36 (17%) with HIV (PLH)] were enrolled. Median age was 52 years (IQR 42,60) and most subjects were male (71%). 83% PLH were on antiretroviral therapy (ART). Hepatitis B surface antigen (HBsAg) positivity was similar between the two groups [91/177 (51%) without HIV vs. 18/36 (50%) with HIV; p = 0.86]. 46/213 (22%) subjects had active hepatitis C (anti-HCV+/HCV RNA>10 IU/mL). Cirrhosis was more common in PLH but there were no other significant differences in clinical and tumor characteristics between the groups. Overall, 99% subjects were symptomatic and 78% in late-stage HCC. Median overall survival was significantly shorter in PLH vs. without HIV (0.98 months vs 3.02 months, HR = 1.55, 95%CI 1.02, 2.37, p = 0.04). This association was not significant after adjusting for known risk factors including gender, current alcohol use, alpha-fetoprotein (AFP), albumin, and total bilirubin (HR = 1.38, 95%CI 0.84, 2.29, p = 0.21). CONCLUSION HCC presented late with an extremely poor overall prognosis, highlighting the urgent need for more intensive surveillance in Nigeria to diagnose HCC at earlier stages. Early diagnosis and management of viral hepatitis, and access to HCC therapies, could prevent early mortality among persons with HCC, especially among PLH.
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Affiliation(s)
| | | | | | | | - Kristen Bell
- Feinberg School of Medicine - Northwestern University, Chicago, Illinois, United States of America
| | | | | | | | - Revika Singh
- Feinberg School of Medicine - Northwestern University, Chicago, Illinois, United States of America
| | - Kwang-Youn Kim
- Feinberg School of Medicine - Northwestern University, Chicago, Illinois, United States of America
| | | | | | | | | | - Marion G. Peters
- Feinberg School of Medicine - Northwestern University, Chicago, Illinois, United States of America
| | - Lewis R. Roberts
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota, United States of America
| | - Lifang Hou
- Feinberg School of Medicine - Northwestern University, Chicago, Illinois, United States of America
| | - Robert L. Murphy
- Feinberg School of Medicine - Northwestern University, Chicago, Illinois, United States of America
| | - Claudia A. Hawkins
- Feinberg School of Medicine - Northwestern University, Chicago, Illinois, United States of America
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Sengayi-Muchengeti M, Singh E, Chen WC, Bradshaw D, de Villiers CB, Newton R, Waterboer T, Mathew CG, Sitas F. Thirteen cancers associated with HIV infection in a Black South African cancer patient population (1995-2016). Int J Cancer 2023; 152:183-194. [PMID: 36054877 DOI: 10.1002/ijc.34236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 10/05/2021] [Accepted: 10/27/2021] [Indexed: 11/11/2022]
Abstract
South Africa's HIV epidemic has evolved over time in terms of numbers of people living with HIV, access to antiretroviral treatment (ART) and age. These changes have profoundly influenced local cancer patterns. The Johannesburg Cancer Study has, over a period of 22 years (1995-2016), recruited over 20 000 incident black cancer patients who consented to provide answers to a questionnaire and blood samples (serum, DNA). This has presented a unique opportunity to examine the evolving association of HIV with cancer in Africa. We used logistic regression models to explore case-control associations between specific cancers and HIV, using participants with non-infection related cancers as controls. Using data of 20 835 cancer patients with confirmed HIV status, we found the following cancers to be associated with HIV: Kaposi's sarcoma (ORadj ; 95%CI): (99.1;72.6-135.1), non-Hodgkin lymphoma (11.3;9.3-13.6), cervical cancer (2.7;2.4-3.0), Hodgkin lymphoma (3.1;2.4-4.2), cancer of the eye/conjunctiva (18.7;10.1-34.7), anogenital cancers (anus [2.1;1.4-3.2], penis [5.4;2.7-10.5], vulva [4.8;3.5-6.4], vagina [5.5;3.0-10.2]), oropharyngeal cancer (1.6;1.3-1.9), squamous cell carcinoma of the skin (3.5;2.4-4.9), melanoma (2.0;1.2-3.5) and cancer of the larynx (1.7;1.3-2.4). Kaposi's sarcoma odds ratios increased from the pre-ART (1995-2004) to the early ART (2005-2009) period but declined in the late ART (2010-2016) period. Odds ratios for cancers of the eye/conjunctiva, cervix, penis and vulva continued to increase in recent ART periods. Our study confirms the spectrum of HIV-associated cancers found in other African settings. The odds ratios of conjunctival and HPV-related cancers continue to rise in the ART era as the HIV positive population ages.
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Affiliation(s)
- Mazvita Sengayi-Muchengeti
- National Cancer Registry, National Health Laboratory Service, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Elvira Singh
- National Cancer Registry, National Health Laboratory Service, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Wenlong Carl Chen
- National Cancer Registry, National Health Laboratory Service, Johannesburg, South Africa
- Sydney Brenner Institute for Molecular Bioscience, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Debbie Bradshaw
- Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Chantal Babb de Villiers
- Division of Human Genetics, National Health Laboratory Service and School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Robert Newton
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- University of York, York, UK
| | - Tim Waterboer
- Infections and Cancer Epidemiology Division, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christopher G Mathew
- Sydney Brenner Institute for Molecular Bioscience, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Human Genetics, National Health Laboratory Service and School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Freddy Sitas
- Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa
- Center for Primary Health Care and Equity, School of Population Health, University of New South Wales Sydney, Sydney, New South Wales, Australia
- Menzies Center of Health Policy, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
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Jonas E, Bernon M, Robertson B, Kassianides C, Keli E, Asare KO, Alatise IO, Okello M, Blondel NO, Mulehane KO, Abubeker ZA, Nogoud AA, Nashidengo PR, Chihaka O, Tzeuton C, Dusheiko G, Sonderup M, Spearman CW. Treatment of hepatocellular carcinoma in sub-Saharan Africa: challenges and solutions. Lancet Gastroenterol Hepatol 2022; 7:1049-1060. [PMID: 35810767 DOI: 10.1016/s2468-1253(22)00042-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 01/30/2022] [Accepted: 02/02/2022] [Indexed: 06/15/2023]
Abstract
Most patients who develop hepatocellular carcinoma reside in resource-poor countries, a category that includes most countries in sub-Saharan Africa. Age-standardised incidence rates of hepatocellular carcinoma in western, central, eastern, and southern Africa is 6·53 per 100 000 inhabitants to 11·1 per 100 000 inhabitants. In high-income countries, around 40% of patients are diagnosed at an early stage, in which interventions with curative intent or palliative interventions are possible. By contrast, 95% of patients with hepatocellular carcinoma in sub-Saharan Africa present with advanced or terminal disease. In high-income countries, targets of 30-40% that have been set for intervention with curative intent are regularly met, with expected 5-year overall survival rates in the region of 70%. These outcomes are in sharp contrast with the very small proportion of patients in sub-Saharan Africa who are treated with curative intent. Primary prevention through the eradication and reduction of risk factors is still suboptimal because of logistical challenges. The challenges facing primary prevention, in combination with difficult-to-manage historic and emerging risk factors, such as ethanol overconsumption and metabolic dysfunction-associated liver disease, mandates secondary prevention for populations at risk through screening and surveillance. Although the increased treatment needs yielded by screening and surveillance in high-income countries are manageable by the incremental expansion of existing interventional resources, the lack of resources in sub-Saharan Africa will undermine the possible benefits of secondary prevention. An estimate of the projected effect of the introduction and expansion of screening and surveillance, resulting in stage migration and possibilities for active interventions for hepatocellular carcinoma, would facilitate optimal planning and development of resources.
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Affiliation(s)
- Eduard Jonas
- Department of Surgery, University of Cape Town, Cape Town, South Africa.
| | - Marc Bernon
- Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Barbara Robertson
- Division of Radiation Oncology, Department of Radiation Medicine, University of Cape Town, Cape Town, South Africa
| | - Chris Kassianides
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Elie Keli
- Department of General and Digestive Surgery, Hôpital Militaire d'Abidjan, Abidjan, Côte d'Ivoire
| | - Kwaku Offei Asare
- Department of Surgery, Korle Bu Teaching Hospital and the University of Ghana Medical School, Accra, Ghana
| | - Isaac Olusegun Alatise
- Department of Surgery, Obafemi Awolowo University, Obafemi Awolowo University Teaching Hospital Complex, Ile Ife, Nigeria
| | - Michael Okello
- Department of Surgery, Uganda Martyrs Hospital Lubaga, Kampala, Uganda
| | - Nana Oumarou Blondel
- Centre Hospitalier d'Essos and Department of Surgery, University of Yaoundé, Yaoundé, Cameroon
| | | | - Zeki Abdurahman Abubeker
- Department of Surgery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Pueya Rashid Nashidengo
- Department of Surgery, Windhoek Central Hospital, University of Namibia School of Medicine, Windhoek, Namibia
| | - Onesai Chihaka
- Department of Surgery, University of Zimbabwe, Harare, Zimbabwe
| | - Christian Tzeuton
- Faculty of Medicine and Pharmaceutical Sciences of Douala, University of Douala, Douala, Cameroon
| | - Geoffrey Dusheiko
- Institute of Liver Studies, King's College Hospital, London, UK; University College London Medical School, London, UK
| | - Mark Sonderup
- Division of Hepatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - C Wendy Spearman
- Division of Hepatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Abstract
INTRODUCTION Hepatocellular carcinoma (HCC) is the sixth most common cancer and the third-leading cause of cancer-related mortality in the world. AREAS COVERED This review will discuss risk factors, demographic differences, global trends, and the economic burden of HCC. Viral hepatitis, particularly hepatitis B virus (HBV) infection, is the most common underlying liver disease leading to HCC in those with cirrhosis. Other important risk factors include alcoholic liver disease, nonalcoholic fatty liver disease, metabolic syndrome, etc. With the introduction of direct-acting antiviral agents for hepatitis C virus infection, routine vaccination against HBV, and increasing support for robust public screening programs, the incidence rates for HCC due to viral hepatitis is falling in many countries. Meanwhile, the prevalence of obesity and metabolic syndrome are on the rise, as is NAFLD-related HCC incidence. Asia and Africa have the highest incidence rates of HCC. In multiethnic countries, racial and ethnic minorities experience disparities in HCC incidence as well as mortality, representing an essential area for improvement in terms of healthcare inequity. EXPERT OPINION Interventions to minimize the global burden of HCC aim to reduce rates of the most common risk factors and implement effective treatment of underlying etiology and comprehensive screening programs for HCC.
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Affiliation(s)
- Peter Konyn
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Donghee Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
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Kedar Mukthinuthalapati VVP, Sewram V, Ndlovu N, Kimani S, Abdelaziz AO, Chiao EY, Abou-Alfa GK. Hepatocellular Carcinoma in Sub-Saharan Africa. JCO Glob Oncol 2021; 7:756-766. [PMID: 34043413 PMCID: PMC8457845 DOI: 10.1200/go.20.00425] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
More than 80% of global hepatocellular carcinoma (HCC) patients are estimated to occur in sub-Saharan Africa (SSA) and Eastern Asia. The most common risk factor of HCC in SSA is chronic hepatitis B virus (HBV) infection, with the incidence highest in West Africa. HBV is highly endemic in SSA and is perpetuated by incomplete adherence to birth dose immunization, lack of longitudinal follow-up care, and impaired access to antiviral therapy. HBV may directly cause HCC through somatic genetic alterations or indirectly through altered liver function and liver cirrhosis. Other risk factors of HCC in SSA include aflatoxins and, to a lesser extent, African iron overload. HIV plus HBV co-infection increases the risk of developing HCC and is increasingly becoming more common because of improving the survival of patients with HIV infection. Compared with the rest of the world, patients with HCC in SSA have the lowest survival. This is partly due to the late presentation of HCC with advanced symptomatic disease as a result of underdeveloped surveillance practices. Moreover, access to care and resource limitations further limit outcomes for the patients who receive a diagnosis in SSA. There is a need for multipronged strategies to decrease the incidence of HCC and improve its outcomes in SSA.
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Affiliation(s)
| | - Vikash Sewram
- Department of Global Health, Faculty of Medicine and Health Sciences, African Cancer Institute, Stellenbosch University, Cape Town, South Africa
| | - Ntokozo Ndlovu
- University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Stephen Kimani
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | - Ghassan K Abou-Alfa
- Memorial Sloan Kettering Cancer Center, New York, NY.,Weill Medical College at Cornell University, New York, NY
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Bahnassy AA, Abdellateif MS, Zekri ARN. Cancer in Africa: Is It a Genetic or Environmental Health Problem? Front Oncol 2020; 10:604214. [PMID: 33409154 PMCID: PMC7781064 DOI: 10.3389/fonc.2020.604214] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 10/19/2020] [Indexed: 12/26/2022] Open
Abstract
Patients of African ancestry have the poorest outcome and the shortest survival rates from cancer globally. This could be attributed to many variables including racial, biological, socioeconomic and sociocultural factors (either single, multiple or combined), which may be responsible for this major health problem. We sought to assess the most common types of cancer that endanger the health of the African people, and tried to investigate the real differences between African and other Non-African patients regarding incidence, prevalence and mortality rates of different cancers. Therefore, identifying the underlying aetiological causes responsible for the increased incidence and mortality rates of African patients will allow for changing the current plans, to make optimized modalities for proper screening, diagnosis and treatment for those African patients, in order to improve their survival and outcomes.
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Affiliation(s)
- Abeer A Bahnassy
- Tissue Culture and Cytogenetics Unit, Pathology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Mona S Abdellateif
- Medical Biochemistry and Molecular Biology, Cancer Biology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Abdel-Rahman N Zekri
- Molecular Virology and Immunology Unit, Cancer Biology Department, National Cancer Institute, Cairo University, Cairo, Egypt
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Tachi K, Agyei-Nkansah A, Archampong T. Hepatocellular carcinoma in Ghana: a retrospective analysis of a tertiary hospital data. Pan Afr Med J 2020; 36:43. [PMID: 32774619 PMCID: PMC7388599 DOI: 10.11604/pamj.2020.36.43.21085] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 02/19/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Hepatocellular carcinoma (HCC) is a cancer of global public health concern because of its high incidence and mortality. The impact is greatest in areas with high prevalence of its major risk factors including chronic hepatitis B virus (HBV). HBV is endemic in Ghana but a comprehensive data on HCC is lacking. The aim of this study was to describe the clinical, laboratory and radiological features of HCC at the Korle Bu Teaching Hospital in Ghana. METHODS The medical records of 194 HCC cases attended to at the Gastrointestinal Clinic of the Korle Bu Teaching Hospital between January 2015 and December 2018 were retrospectively analyzed for demographic, clinical, laboratory and radiological data. RESULTS The male: female ratio was 2:1 and mean age was 45.2 years. Weight loss and abdominal pain were the major presenting symptoms. No patients were identified through surveillance. HBsAg was positive in 109/145 (75.2%) of cases tested. Sixty-five (59.6%) of 109 HBsAg positives were aware of their HBsAg status but only 3 were receiving medical follow ups prior to the diagnosis of HCC. Raised alpha-fetoprotein level >165.2 IU/ML was found in 53.9%. One hundred and forty-four patients were eligible for only analgesia. CONCLUSION HBV infection is the leading aetiologial risk factor associated with HCC. Majority of HBV carriers are aware of their status but do not receive care prior to HCC diagnosis. Majority present late and are eligible for only palliative treatment. Improvement in the health seeking behavior of HBV carriers can aid early detection of HCC.
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Affiliation(s)
- Kenneth Tachi
- Department of Medicine, Medical School, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Adwoa Agyei-Nkansah
- Department of Medicine, Medical School, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Timothy Archampong
- Department of Medicine, Medical School, College of Health Sciences, University of Ghana, Accra, Ghana
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Abstract
Liver cancer is one of the leading causes of cancer-related mortality around the world. Hepatocellular carcinoma (HCC) is the primary cancer of the liver, accounting for the majority of liver cancers. The risk factors associated with HCC include chronic infections with HBV and HCV, alcoholic liver disease, and nonalcoholic fatty liver disease. Additionally, male patients have higher risk for than females, and the risk increases with older age. Mortality rates for HCC parallel its increasing incidence rates. In this context, incidence rate for HCC shows geographic variations in different parts of the world and is heavily affected by regional differences in risk factor for liver disease. The highest incidence rates for HCC are observed in Asia and Africa, while Europe and North America have lower rates. In fact, HBV is still regarded as the leading cause of HCC globally, while HCV is the most common cause of HCC in the USA. Recently, it has been suggested that HCC cases related to nonalcoholic fatty liver disease is on the rise, while the proportion of HCC attributed to alcoholic liver disease remains stable.
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11
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Amadi CN, Orisakwe OE. Herb-Induced Liver Injuries in Developing Nations: An Update. TOXICS 2018; 6:toxics6020024. [PMID: 29673137 PMCID: PMC6027193 DOI: 10.3390/toxics6020024] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 04/03/2018] [Accepted: 04/14/2018] [Indexed: 12/16/2022]
Abstract
The last few decades have seen a rise in the use of herbal supplements, natural products, and traditional medicines. However, there are growing concerns related to the safety and toxicities of these medicines. These herbal medicines are associated with complications such as liver damage with a high incidence of mortalities and morbidities. Clinical manifestations range from asymptomatic cases with abnormal liver functions tests to sudden and severe liver failure necessitating liver transplantation. This work aimed to review the etiology, risk factors, diagnosis, clinical manifestations and selected clinical case reports of herbal hepatotoxicity in developing nations. PubMed and Google Scholar searches were undertaken to identify relevant literature. Furthermore, we scanned the reference lists of the primary and review articles to identify publications not retrieved by electronic searches. Little data exists on clinical cases of herb-induced liver injury in some developing countries such as Nigeria, as most incidences are either not reported to health care providers or reports from hospitals go unpublished. Studies in Nigeria have highlighted a possible correlation between use of herbs and liver disease. In Uganda, and association between the use of traditional herbal medicine with liver fibrosis in HIV-infected and non-HIV patients was demonstrated. Reports from China have revealed incidences of acute liver failure as a result of herbal medicine use. The actual incidence and prevalence of HILI in developing nations remain largely unknown due to both poor pharmacovigilance programs and non-application of emerging technologies. Improving education and public awareness of the potential risks of herbals and herbal products is desirable to ensure that suspected adverse effects are formally reported. There is need for stricter regulations and pre-clinical studies necessary for efficacy and safety.
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Affiliation(s)
- Cecilia Nwadiuto Amadi
- Department of Experimental Pharmacology & Toxicology, Faculty of Pharmacy, University of Port-Harcourt, PMB, 5323 Port Harcourt, Rivers State, Nigeria.
| | - Orish Ebere Orisakwe
- Department of Experimental Pharmacology & Toxicology, Faculty of Pharmacy, University of Port-Harcourt, PMB, 5323 Port Harcourt, Rivers State, Nigeria.
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12
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Ladeira C, Frazzoli C, Orisakwe OE. Engaging One Health for Non-Communicable Diseases in Africa: Perspective for Mycotoxins. Front Public Health 2017; 5:266. [PMID: 29085817 PMCID: PMC5650707 DOI: 10.3389/fpubh.2017.00266] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 09/15/2017] [Indexed: 01/14/2023] Open
Abstract
The role of mycotoxins-e.g., aflatoxins, ochratoxins, trichothecenes, zearalenone, fumonisins, tremorgenic toxins, and ergot alkaloids-has been recognized in the etiology of a number of diseases. In many African countries, the public health impact of chronic (indoor) and/or repeated (dietary) mycotoxin exposure is largely ignored hitherto, with impact on human health, food security, and export of African agricultural food products. Notwithstanding, African scientific research reached milestones that, when linked to findings gained by the international scientific community, make the design and implementation of science-driven governance schemes feasible. Starting from Nigeria as leading African Country, this article (i) overviews available data on mycotoxins exposure in Africa; (ii) discusses new food safety issues, such as the environment-feed-food chain and toxic exposures of food producing animals in risk assessment and management; (iii) identifies milestones for mycotoxins risk management already reached in West Africa; and (iv) points out preliminary operationalization aspects for shielding communities from direct (on health) and indirect (on trade, economies, and livelihoods) effects of mycotoxins. An African science-driven engaging of scientific knowledge by development actors is expected therefore. In particular, One health/One prevention is suggested, as it proved to be a strategic and sustainable development framework.
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Affiliation(s)
- Carina Ladeira
- Environment and Health Research Group, Escola Superior de Tecnologia da Saúde de Lisboa – Instituto Politécnico de Lisboa (ESTeSL – IPL), Lisboa, Portugal
- Grupo de Investigação em Genética e Metabolismo, Escola Superior de Tecnologia da Saúde de Lisboa – Instituto Politécnico de Lisboa (ESTeSL – IPL), Lisboa, Portugal
- Centro de Investigação e Estudos em Saúde Pública, Escola Nacional de Saúde Pública, ENSP, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Chiara Frazzoli
- Department for Cardiovascular, Dysmetabolic and Aging-Associated Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Orish Ebere Orisakwe
- Toxicology Unit, Faculty of Pharmacy, University of Port Harcourt, Port Harcourt, Nigeria
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Odutola MK, Jedy-Agba EE, Dareng EO, Adebamowo SN, Oga EA, Igbinoba F, Otu T, Ezeome E, Hassan R, Adebamowo CA. Cancers Attributable to Alcohol Consumption in Nigeria: 2012-2014. Front Oncol 2017; 7:183. [PMID: 28971062 PMCID: PMC5609586 DOI: 10.3389/fonc.2017.00183] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 08/08/2017] [Indexed: 12/15/2022] Open
Abstract
Introduction Alcohol consumption has been identified as a risk factor for many cancers but less attention has been paid to the fraction of those cancers that are attributable to alcohol consumption. In this study, we evaluated the incidence and population attributable fraction (PAF) of cancers associated with alcohol consumption in Nigeria. Methods We obtained data on incidence of cancers from two population-based cancer registries (PBCRs) in Nigeria and identified cancer sites for which there is strong evidence of an association with alcohol consumption based on the International Agency for Research on Cancer Monograph 100E. We computed the PAF for each cancer site by age and sex, using prevalence and relative risk estimates from previous studies. Results Between 2012 and 2014 study period, the PBCRs reported 4,336 cancer cases of which 1,627 occurred in males, and 2,709 occurred in females. Of these, a total of 1,808 cancer cases, 339 in males and 1,469 in females, were associated with alcohol intake. The age standardized incidence rate (ASR) of alcohol associated cancers was 77.3 per 100,000. Only 4.3% (186/4,336) of all cancer cases or 10.3% (186/1,808) of alcohol associated cancers were attributable to alcohol consumption. Some 42.5% (79/186) of these cancers occurred in males while 57.5% (107/186) occurred in females. The ASR of cancers attributable to alcohol in this population was 7.2 per 100,000. The commonest cancers attributable to alcohol consumption were cancers of the oral cavity and pharynx in men and cancer of the breast in women. Conclusion Our study shows that 4.3% of incident cancers in Nigeria can be prevented by avoiding alcohol consumption. While the incidence of cancers associated with alcohol intake is high, the proportion attributable to alcohol consumption is much lower suggesting that the number of cancers that may be prevented by eliminating alcohol intake in this population is relatively low.
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Affiliation(s)
| | - Elima E Jedy-Agba
- Institute of Human Virology, Abuja, Nigeria.,Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Eileen O Dareng
- Center for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Sally N Adebamowo
- Department of Epidemiology and Public Health, Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Emmanuel A Oga
- Battelle Memorial Institute, Baltimore, MD, United States
| | | | - Theresa Otu
- University of Abuja Teaching Hospital, Gwagwalada, Nigeria
| | | | | | - Clement A Adebamowo
- Institute of Human Virology, Abuja, Nigeria.,Department of Epidemiology and Public Health, Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, United States.,Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, United States
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14
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Grant J, Agbaji O, Kramvis A, Yousif M, Auwal M, Penugonda S, Ugoagwu P, Murphy R, Hawkins C. Hepatitis B virus sequencing and liver fibrosis evaluation in HIV/HBV co-infected Nigerians. Trop Med Int Health 2017; 22:744-754. [PMID: 28376292 DOI: 10.1111/tmi.12873] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Molecular characteristics of hepatitis B virus (HBV), such as genotype and genomic mutations, may contribute to liver-related morbidity and mortality. The association of these characteristics with liver fibrosis severity in sub-Saharan Africa is uncertain. We aimed to characterise molecular HBV features in human immunodeficiency virus (HIV)/HBV co-infected Nigerians and evaluate associations between these characteristics and liver fibrosis severity before and after antiretroviral therapy (ART) initiation. METHODS HIV/HBV co-infected Nigerians underwent liver fibrosis estimation by transient elastography (TE) prior to and 36 months after ART initiation. Basal core promoter/precore (BCP/PC) and preS1/preS2/S regions of HBV were sequenced from baseline plasma samples. We evaluated associations between HBV mutations and liver fibrosis severity by univariate and multivariable regression. RESULTS At baseline, 94 patients underwent TE with median liver stiffness of 6.4 (IQR 4.7-8.7) kPa. Patients were predominantly infected with HBV genotype E (45/46) and HBe-antigen negative (75/94, 79.8%). We identified BCP A1762T/G1764A in 15/35 (43%), PC G1896A in 20/35 (57%), 'a' determinant mutations in 12/45 (26.7%) and preS2 deletions in 6/16 (37.5%). PreS2 mutations were associated with advanced fibrosis in multivariable analysis. At follow-up, median liver stiffness was 5.2 (IQR 4.1-6.6) kPa. No HBV molecular characteristics were associated with lack of fibrosis regression, although HIV virologic control, body mass index (BMI) and baseline CD4+ T-cell count were associated with a decline in fibrosis stage. CONCLUSION Frequent BCP/PC and preS1/preS2/S mutations were found in ART-naïve HIV/HBV co-infected Nigerians. Median liver stiffness declined after initiation of ART, regardless of pre-ART HBV mutational pattern or virologic characteristics.
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Affiliation(s)
- Jennifer Grant
- Department of Medicine, Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Oche Agbaji
- Department of Medicine, University of Jos and Jos University Teaching Hospital, Jos, Nigeria
| | - Anna Kramvis
- School of Clinical Medicine, Faculty of Health Sciences, Hepatitis Virus Diversity Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Mukhlid Yousif
- School of Clinical Medicine, Faculty of Health Sciences, Hepatitis Virus Diversity Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Mu'azu Auwal
- HIV Care and Treatment Center, Jos University Teaching Hospital, Jos, Nigeria
| | - Sudhir Penugonda
- Department of Medicine, Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Placid Ugoagwu
- HIV Care and Treatment Center, Jos University Teaching Hospital, Jos, Nigeria
| | - Robert Murphy
- Department of Medicine, Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Claudia Hawkins
- Department of Medicine, Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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15
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Yang JD, Mohamed EA, Aziz AOA, Shousha HI, Hashem MB, Nabeel MM, Abdelmaksoud AH, Elbaz TM, Afihene MY, Duduyemi BM, Ayawin JP, Gyedu A, Lohouès-Kouacou MJ, Ndam AWN, Moustafa EF, Hassany SM, Moussa AM, Ugiagbe RA, Omuemu CE, Anthony R, Palmer D, Nyanga AF, Malu AO, Obekpa S, Abdo AE, Siddig AI, Mudawi HMY, Okonkwo U, Kooffreh-Ada M, Awuku YA, Nartey YA, Abbew ET, Awuku NA, Otegbayo JA, Akande KO, Desalegn HM, Omonisi AE, Ajayi AO, Okeke EN, Duguru MJ, Davwar PM, Okorie MC, Mustapha S, Debes JD, Ocama P, Lesi OA, Odeghe E, Bello R, Onyekwere C, Ekere F, Igetei R, Mah'moud MA, Addissie B, Ali HM, Gores GJ, Topazian MD, Roberts LR. Characteristics, management, and outcomes of patients with hepatocellular carcinoma in Africa: a multicountry observational study from the Africa Liver Cancer Consortium. Lancet Gastroenterol Hepatol 2016; 2:103-111. [PMID: 28403980 DOI: 10.1016/s2468-1253(16)30161-3] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 09/29/2016] [Accepted: 09/30/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Hepatocellular carcinoma is a leading cause of cancer-related death in Africa, but there is still no comprehensive description of the current status of its epidemiology in Africa. We therefore initiated an African hepatocellular carcinoma consortium aiming to describe the clinical presentation, management, and outcomes of patients with hepatocellular carcinoma in Africa. METHODS We did a multicentre, multicountry, retrospective observational cohort study, inviting investigators from the African Network for Gastrointestinal and Liver Diseases to participate in the consortium to develop hepatocellular carcinoma research databases and biospecimen repositories. Participating institutions were from Cameroon, Egypt, Ethiopia, Ghana, Ivory Coast, Nigeria, Sudan, Tanzania, and Uganda. Clinical information-demographic characteristics, cause of disease, liver-related blood tests, tumour characteristics, treatments, last follow-up date, and survival status-for patients diagnosed with hepatocellular carcinoma between Aug 1, 2006, and April 1, 2016, were extracted from medical records by participating investigators. Because patients from Egypt showed differences in characteristics compared with patients from the other countries, we divided patients into two groups for analysis; Egypt versus other African countries. We undertook a multifactorial analysis using the Cox proportional hazards model to identify factors affecting survival (assessed from the time of diagnosis to last known follow-up or death). FINDINGS We obtained information for 2566 patients at 21 tertiary referral centres (two in Egypt, nine in Nigeria, four in Ghana, and one each in the Ivory Coast, Cameroon, Sudan, Ethiopia, Tanzania, and Uganda). 1251 patients were from Egypt and 1315 were from the other African countries (491 from Ghana, 363 from Nigeria, 277 from Ivory Coast, 59 from Cameroon, 51 from Sudan, 33 from Ethiopia, 21 from Tanzania, and 20 from Uganda). The median age at which hepatocellular carcinoma was diagnosed significantly later in Egypt than the other African countries (58 years [IQR 53-63] vs 46 years [36-58]; p<0·0001). Hepatitis C virus was the leading cause of hepatocellular carcinoma in Egypt (1054 [84%] of 1251 patients), and hepatitis B virus was the leading cause in the other African countries (597 [55%] of 1082 patients). Substantially fewer patients received treatment specifically for hepatocellular carcinoma in the other African countries than in Egypt (43 [3%] of 1315 vs 956 [76%] of 1251; p<0·0001). Among patients with survival information (605 [48%] of 1251 in Egypt and 583 [44%] of 1315 in other African countries), median survival was shorter in the other African countries than in Egypt (2·5 months [95% CI 2·0-3·1] vs 10·9 months [9·6-12·0]; p<0·0001). Factors independently associated with poor survival were: being from an African countries other than Egypt (hazard ratio [HR] 1·59 [95% CI 1·13-2·20]; p=0·01), hepatic encephalopathy (2·81 [1·72-4·42]; p=0·0004), diameter of the largest tumour (1·07 per cm increase [1·04-1·11]; p<0·0001), log α-fetoprotein (1·10 per unit increase [1·02-1·20]; p=0·0188), Eastern Cooperative Oncology Group performance status 3-4 (2·92 [2·13-3·93]; p<0·0001) and no treatment (1·79 [1·44-2·22]; p<0·0001). INTERPRETATION Characteristics of hepatocellular carcinoma differ between Egypt and other African countries. The proportion of patients receiving specific treatment in other African countries was low and their outcomes were extremely poor. Urgent efforts are needed to develop health policy strategies to decrease the burden of hepatocellular carcinoma in Africa. FUNDING None.
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Affiliation(s)
- Ju Dong Yang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Essa A Mohamed
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Ashraf O Abdel Aziz
- Endemic Medicine and Hepatogastroenterology Department, University of Cairo, Cairo, Egypt
| | - Hend I Shousha
- Endemic Medicine and Hepatogastroenterology Department, University of Cairo, Cairo, Egypt
| | - Mohamed B Hashem
- Endemic Medicine and Hepatogastroenterology Department, University of Cairo, Cairo, Egypt
| | - Mohamed M Nabeel
- Endemic Medicine and Hepatogastroenterology Department, University of Cairo, Cairo, Egypt
| | - Ahmed H Abdelmaksoud
- Department of Diagnostic and Interventional Radiology, University of Cairo, Cairo, Egypt
| | - Tamer M Elbaz
- Endemic Medicine and Hepatogastroenterology Department, University of Cairo, Cairo, Egypt
| | - Mary Y Afihene
- Department of Internal Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Babatunde M Duduyemi
- Department of Pathology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Joshua P Ayawin
- Department of Internal Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Adam Gyedu
- Department of Surgery, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Marie-Jeanne Lohouès-Kouacou
- Department of Hepatology and Gastroenterology, Centre Hospitalier Universitaire de Cocody, Abidjan, Côte d'Ivoire
| | - Antonin W Ndjitoyap Ndam
- Department of Hepatology and Gastroenterology, Centre Hospitalier Universitaire de Cocody, Abidjan, Côte d'Ivoire
| | - Ehab F Moustafa
- Department of Tropical Medicine and Gastroenterology, Assiut University Hospital, Assiut Governorate, Egypt
| | - Sahar M Hassany
- Department of Tropical Medicine and Gastroenterology, Assiut University Hospital, Assiut Governorate, Egypt
| | - Abdelmajeed M Moussa
- Department of Tropical Medicine and Gastroenterology, Assiut University Hospital, Assiut Governorate, Egypt
| | - Rose A Ugiagbe
- Department of Medicine, University of Benin Teaching Hospital, Benin City, Nigeria
| | - Casimir E Omuemu
- Department of Medicine, University of Benin Teaching Hospital, Benin City, Nigeria
| | - Richard Anthony
- Department of Internal Medicine, Effia Nkwanta Regional Hospital, Sekondi, Ghana
| | - Dennis Palmer
- Department of Internal Medicine, Mbingo Baptist Hospital, Bamenda, Cameroon
| | - Albert F Nyanga
- Department of Internal Medicine, Mbingo Baptist Hospital, Bamenda, Cameroon
| | - Abraham O Malu
- Department of Medicine, Benue State University Teaching Hospital, Benue, Nigeria
| | - Solomon Obekpa
- Department of Medicine, Benue State University Teaching Hospital, Benue, Nigeria
| | | | | | - Hatim M Y Mudawi
- Department of Internal Medicine, University of Khartoum, Khartoum, Sudan
| | - Uchenna Okonkwo
- Department of Internal Medicine, University of Calabar Teaching Hospital, Calabar, Nigeria
| | - Mbang Kooffreh-Ada
- Department of Internal Medicine, University of Calabar Teaching Hospital, Calabar, Nigeria
| | - Yaw A Awuku
- Department of Internal Medicine, School of Medical Sciences, Cape Coast, Ghana
| | - Yvonne A Nartey
- Department of Internal Medicine, School of Medical Sciences, Cape Coast, Ghana
| | - Elizabeth T Abbew
- Department of Internal Medicine, School of Medical Sciences, Cape Coast, Ghana
| | - Nana A Awuku
- Department of Internal Medicine, School of Medical Sciences, Cape Coast, Ghana
| | | | | | - Hailemichael M Desalegn
- Department of Internal Medicine, St. Paul's Hospital Millenium Medical College, Addis Ababa, Ethiopia
| | - Abidemi E Omonisi
- Department of Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria
| | - Akande O Ajayi
- Department of Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria
| | - Edith N Okeke
- Department of Medicine, University of Jos/Jos University Teaching Hospital, Jos, Nigeria
| | - Mary J Duguru
- Department of Medicine, University of Jos/Jos University Teaching Hospital, Jos, Nigeria
| | - Pantong M Davwar
- Department of Medicine, University of Jos/Jos University Teaching Hospital, Jos, Nigeria
| | - Michael C Okorie
- Department of Medicine, University of Jos/Jos University Teaching Hospital, Jos, Nigeria
| | - Shettima Mustapha
- Department of Medicine, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
| | - Jose D Debes
- Department of Medicine, University of Minnesota, MN, USA; Department of Medicine, Arusha Lutheran Medical Center, Arusha, Tanzania
| | - Ponsiano Ocama
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Olufunmilayo A Lesi
- Division of Gastroenterology and Hepatology, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Emuobor Odeghe
- Division of Gastroenterology and Hepatology, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Ruth Bello
- Department of Medicine, Dalhatu Araf Specialist Hospital, Lafia, Nigeria
| | - Charles Onyekwere
- Department of Medicine, Lagos State University Teaching Hospital, Lagos, Nigeria
| | - Francis Ekere
- Department of Medicine, Lagos State University Teaching Hospital, Lagos, Nigeria
| | - Rufina Igetei
- Department of Medicine, Lagos State University Teaching Hospital, Lagos, Nigeria
| | | | - Benyam Addissie
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Hawa M Ali
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Gregory J Gores
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Mark D Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Lewis R Roberts
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
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