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Ma W, Zhang X, Zhao R, Tang Y, Zhu X, Liu L, Xu M, Wang G, Peng P, Liu J, Liu Z. Effectiveness and potential mechanism of Jiawei-Xiaoyao-San for hyperthyroidism: a systematic review. Front Endocrinol (Lausanne) 2023; 14:1241962. [PMID: 37780612 PMCID: PMC10534980 DOI: 10.3389/fendo.2023.1241962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 08/21/2023] [Indexed: 10/03/2023] Open
Abstract
Objectives To evaluate the effectiveness and potential mechanism of traditional Chinese medicine Jiawei-Xiaoyao-San (JWXYS) as an adjunct or mono- therapy for antithyroid drugs (ATDs) in the treatment of hyperthyroidism. Methods Eight databases and three trial registries were searched from inception until May 2023. Randomized controlled trials (RCTs) were included and meta-analysis was conducted using RevMan 5.4 and Stata 14.0. The Cochrane risk of bias (ROB) tool 1.0 and GRADE tool was used for quality appraisal. The findings from case reports using mono-JWXYS and pharmacological studies were summarized in tables. Results Thirteen RCTs with 979 participants were included. The majority of the included studies were assessed as high risk of bias in one ROB domain. Compared with ATDs, JWXYS plus ATDs resulted in lower free triiodothyronine (FT3) (MD = -1.31 pmol/L, 95% CI [-1.85, -0.76]; low-certainty), lower free thyroxine (MD = -3.24 pmol/L, 95% CI [-5.06, -1.42]; low-certainty), higher thyroid stimulating hormone (MD = 0.42 mIU/L, 95% CI [0.26, 0.59]; low-certainty), higher effectiveness rate of traditional Chinese medicine syndrome (RR = 1.28, 95% CI [1.08, 1.52]; low-certainty), lower goiter score (MD = -0.66, 95% CI [-1.04, -0.29]; very low-certainty), lower thyrotrophin receptor antibody (SMD = -0.44, 95% CI [-0.73, -0.16]; low-certainty) and fewer adverse events (AEs) (RR = 0.34, 95% CI [0.18, 0.67]; moderate-certainty). Compared with regular dosage of ATDs, JWXYS plus half-dose ATDs resulted in fewer AEs (RR = 0.24, 95% CI [0.10, 0.59]; low-certainty). Compared with ATDs in 1 trial, JWXYS resulted in higher FT3, lower goiter score and fewer AEs. Three case reports showed that the reasons patients sought TCM-only treatment include severe AEs and multiple relapses. Three pharmacological studies demonstrated that JWXYS restored Th17/Treg balance, lowered deiodinases activity, regulated thyroid cell proliferation and apoptosis, and alleviated liver oxidative stress in mouse or rat models. Conclusion JWXYS may enhance the effectiveness of ATDs for hyperthyroidism, particularly in relieving symptoms and reducing AEs. Mono-JWXYS is not recommended except in patients intolerant to ATDs. The findings should be interpreted with caution due to overall high risk of bias. Further pharmacological studies with more reliable models are needed. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42023394923.
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Affiliation(s)
- Wenxin Ma
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Xiaowen Zhang
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Ruotong Zhao
- Beijing University of Chinese Medicine, Beijing, China
| | - Yang Tang
- Beijing University of Chinese Medicine, Beijing, China
| | - Xiaoyun Zhu
- Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Longkun Liu
- Beijing University of Chinese Medicine, Beijing, China
| | - Mingyuan Xu
- Beijing University of Chinese Medicine, Beijing, China
| | - Ge Wang
- Guang’anmen Hospital South Campus, China Academy of Chinese Medical Sciences, Beijing, China
| | - Peiyue Peng
- Beijing University of Chinese Medicine, Beijing, China
| | - Jianping Liu
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
- Department of Community Medicine, Faculty of Health Science, UiT The Arctic University of Norway, Tromsø, Norway
| | - Zhaolan Liu
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
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Cortés-Guzmán JS, Veloza KT, Domínguez JD, Pinzón-Tovar A. [Leukocytoclastic vasculitis as an adverse effect of propylthiouracil. A case report]. REVISTA ALERGIA MÉXICO 2023; 70:51-54. [PMID: 37566757 DOI: 10.29262/ram.v70i1.1210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/15/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND The most common cause of hyperthyroidism is Graves' disease. Propylthiouracil (PTU) is one of the drugs used to treat this disease. Leukocytoclastic vasculitis is described among dermatologic adverse effects of PTU. CASE REPORT A 18-year-old woman, allergic to methimazole, developed a vasculitis associated to ANCAs with characteristics of leukocytoclastic vasculitis, associated to PTU treatment. She did not present systemic involvement. PTU treatment was suspended. Two months later, the skin lesions had almost completely resolved. CONCLUSIONS Leukocytoclastic vasculitis should be considered in the spectrum of complications caused by the consumption of propylthiouracil. The lesions can manifest over time, from a few weeks to years after taking the drug. When there is no systemic involvement, propylthiouracil suspension is sufficient to cure the disease.
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Affiliation(s)
- José Santiago Cortés-Guzmán
- Epidemiólogo, residente de tercer año, posgrado de Medicina Interna, Facultad de Salud, Universidad Surcolombiana, Departamento de Medicina Interna, Hospital Universitario Hernando Moncaleano Perdomo, Neiva, Huila, Colombia.
| | - Karen T Veloza
- Estudiante de Medicina, Programa de Medicina, Facultad de Salud, Universidad Surcolombiana, Neiva, Huila, Colombia
| | - Juan D Domínguez
- Médico Internista y Epidemiólogo, servicio de Medicina interna, Hospital Universitario Hernando Moncaleano Perdomo. Docente de la Facultad de Salud, Universidad Surcolombiana, Neiva, Huila, Colombia
| | - Alejandro Pinzón-Tovar
- Médico Internista y Endocrinólogo, Hospital Universitario Hernando Moncaleano Perdomo, Neiva, Huila, Colombia
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Guan YY. Hyperthyroidism with papillary thyroid carcinoma in HIV: Case report and literature review. Heliyon 2023; 9:e14377. [PMID: 36967896 PMCID: PMC10034455 DOI: 10.1016/j.heliyon.2023.e14377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 03/02/2023] [Accepted: 03/02/2023] [Indexed: 03/17/2023] Open
Abstract
The immune function of HIV infected patients is severely damaged, which can cause a series of autoimmune related diseases including hyperthyroidism. Hyperthyroidism includes both primary and secondary hyperthyroidism. Graves' disease is the most common primary hyperthyroidism, and Graves' disease may occur in HIV patients during immune reconstitution after antiretroviral therapy A 47-year-old woman with a history of HIV presented with symptoms related to hyperthyroidism. After antithyroid drug therapy failed, the patient and her families opted for surgical treatment. Postoperative examination revealed papillary thyroid carcinoma.
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Angelovska B, Drakalska Sersemova E, Miceva D, Adji Andov L. Analysis of the drugs consumption for hyperthyroidism in Republic of North Macedonia for the period of 2016-2019. MAKEDONSKO FARMACEVTSKI BILTEN 2022. [DOI: 10.33320/maced.pharm.bull.2022.68.03.233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
- Bistra Angelovska
- Faculty of Medical Sciences, Goce Delcev University, Krste Misirkov bb, 2000 Shtip, Republic of North Macedonia
| | - Elena Drakalska Sersemova
- Faculty of Medical Sciences, Goce Delcev University, Krste Misirkov bb, 2000 Shtip, Republic of North Macedonia
| | - Dijana Miceva
- Faculty of Medical Sciences, Goce Delcev University, Krste Misirkov bb, 2000 Shtip, Republic of North Macedonia
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Morcel P, Hadjadj S, Ansquer C, Yan Lun A, Cariou B, Delemazure Chesneau AS, Le Bras M, Langlois E, Drui D. Démarche diagnostique et prise en charge thérapeutique de l’hyperthyroïdie. Rev Med Interne 2022; 43:233-241. [DOI: 10.1016/j.revmed.2021.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 11/05/2021] [Accepted: 12/23/2021] [Indexed: 11/16/2022]
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Zhang X, Zhang S, Wu R, Li S, Su Y, Zhang P. Prevalence of autoimmune thyroid disease in patients with psoriasis: a meta-analysis. BMJ Open 2022; 12:e055538. [PMID: 35105646 PMCID: PMC8804708 DOI: 10.1136/bmjopen-2021-055538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Psoriasis is a chronic inflammatory disease with autoimmune aetiology. A possible link between psoriasis and autoimmune thyroid disease (AITD) has been suggested in some studies with inconsistent findings. This meta-analysis aims to determine the association between psoriasis and AITD. DESIGN A meta-analysis of observational studies. DATA SOURCES PubMed, EMBASE, Scopus and the Cochrane Library were searched up to 1 November 2021. ELIGIBILITY CRITERIA FOR SELECTING STUDIES We included non-randomised studies, each with over 50 cases in every group, focusing on the rate of comorbidity between psoriasis and AITD. DATA EXTRACTION AND SYNTHESIS Two independent reviewers screened the articles and extracted data. The restricted maximum-likelihood was applied to perform the meta-analysis. OR and 95% CIs were pooled to compare the prevalence of AITD in psoriasis and control groups. Heterogeneity was assessed with I2 statistic. The Newcastle-Ottawa Scale and Agency for Healthcare Research and Quality were applied for quality assessment. The risk of bias was assessed with Risk Of Bias In Non-randomised Studies-of Interventions (ROBINS-I). RESULTS Eleven available studies with data on 253 313 patients with psoriasis and 1 376 533 controls were included. Meta-analysis showed that patients with psoriasis had a higher prevalence of AITD (OR 1.76, 95% CI 1.35 to 2.28, Z=4.25, p<0.01), especially loss-of-function disorder of the thyroid gland. Both thyroglobulin antibodies positive rate (OR 1.98, 95% CI 1.27 to 3.10, Z=3.00, p<0.01) and thyroid peroxidase antibodies positive rate (OR 2.15, 95% CI 1.31 to 3.52, Z=3.05, p<0.01) were also increased in the psoriasis group compared with the control group. CONCLUSIONS Our study indicates that the rate of co-occurring AITD was significantly increased in patients with psoriasis. It suggests that the increased risk of AITD should be concerned in patients with psoriasis. PROSPERO REGISTRATION NUMBER CRD42020206005.
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Affiliation(s)
- Xiaochao Zhang
- Dermatology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Suhan Zhang
- Dermatology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Ruifang Wu
- Dermatology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Siying Li
- Dermatology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Yuwen Su
- Dermatology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Peng Zhang
- Dermatology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
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Tian Y, Li R, Liu Y, Li M, Song Y, Zheng Y, Gao A, Wen Q, Su G, Sun Y. The Risk of Immune-Related Thyroid Dysfunction Induced by PD-1/PD-L1 Inhibitors in Cancer Patients: An Updated Systematic Review and Meta-Analysis. Front Oncol 2021; 11:667650. [PMID: 34322382 PMCID: PMC8312489 DOI: 10.3389/fonc.2021.667650] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 06/25/2021] [Indexed: 12/26/2022] Open
Abstract
Background Thyroid dysfunction is common for cancer patients receiving PD-1/PD-L1 inhibitor therapies. To clarify the incidence risk of thyroid dysfunction would be important for guiding anti-PD-1 and anti-PD-L1 immunotherapy. Therefore, the updated meta-analysis was conducted to evaluate the incidence risk of thyroid dysfunction caused by PD-1/PD-L1 inhibitors. Methods PD-1/PD-L1 inhibitor related clinical trials were collected by a systematic search of the PubMed. Some relevant studies were identified by a manual search. The incidence risk of all grades and grades 3-5 was analyzed and evaluated by random effect model. The Newcastle Ottawa Scale was used for the quality assessment of all clinical trials. Results Forty-three clinical trials were collected. Compared with chemotherapy, the risk of hypothyroidism of all grades was significantly higher (OR=7.15, 95%CI:[4.85, 10.55], I2 = 40%, Z=9.91(P <0.00001)) in PD-1/PD-L1 group. Similar results could also be noted, when the control group was placebo or CTLA-4. When PD-1/PD-L1 was combined with other treatments for cancer patients, the risk of hypothyroidism of all grades was also significantly increased. Similar to the analysis results of hypothyroidism, PD-1/PD-L1 inhibitors played the same role in increasing the risk of hyperthyroidism and thyroiditis. Few significant analysis results was noted, when the risk of thyroid dysfunction of grades 3-5 was assessed. Conclusion Whether used alone or in combination with other anti-tumor drugs, PD-1/PD-L1 inhibitors increased the risk of thyroid dysfunction, especially for hypothyroidism. Furthermore, PD-1/PD-L1 was better than chemotherapy and CTLA-4 in increasing the risk of thyroid dysfunction.
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Affiliation(s)
- Yuan Tian
- Department of Oncology, Jinan Central Hospital Affiliated to Shandong University, Jinan, China.,Special Care Department of Proton Therapy Center, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Ran Li
- Department of Oncology, Jinan Central Hospital, Weifang Medical University, Weifang, China
| | - Yan Liu
- Qilu Hospital of Shandong University, Jinan, China
| | - Meng Li
- Human Resources Department, Jinan Central Hospital Affiliated to Shandong University, Jinan, China
| | - Yuxiao Song
- Jinan Center for Disease Control and Prevention, Jinan, China
| | - Yan Zheng
- Research Center of Translational Medicine, Jinan Central Hospital Affiliated to Shandong First Medical University, Jinan, China.,Research Center of Translational Medicine, Jinan Central Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Aiqin Gao
- Department of Oncology, Jinan Central Hospital Affiliated to Shandong University, Jinan, China
| | - Qing Wen
- Jinan Clinical Research Center of Shandong First Medical University, Jinan, China
| | - Guohai Su
- Department of Cardiovascular Diseases, Jinan Central Hospital Affiliated to Shandong University, Jinan, China
| | - Yuping Sun
- Department of Oncology, Jinan Central Hospital Affiliated to Shandong University, Jinan, China.,Department of Oncology, Jinan Central Hospital Affiliated to Shandong First Medical University, Jinan, China
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Alqahtani HA, Almagsoodi AA, Alshamrani ND, Almalki TJ, Sumaili AM. Common Electrolyte and Metabolic Abnormalities Among Thyroid Patients. Cureus 2021; 13:e15338. [PMID: 34235017 PMCID: PMC8241464 DOI: 10.7759/cureus.15338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2021] [Indexed: 11/05/2022] Open
Abstract
The prevalence of thyroid diseases is high in the general population and causes serious abnormalities and disorders that can affect the quality of life. Many complications can result from poor or inappropriate management of the disease, leading to serious cardiovascular and metabolic complications. In the present review study, we aim to discuss the effect of thyroid diseases on metabolic and electrolyte abnormalities and the potential correlation with some common disorders. Evidence from previous studies has demonstrated that thyroid dysfunctions hugely affect the metabolism of glucose in the bodies of the affected patients, which can lead to the development of both type 1 and 2 diabetes mellitus (DM). Hyperthyroidism can lead to the development of impaired glucose tolerance and secondary diabetes mellitus. These include an increased glycogenolysis and gluconeogenesis process, increased intestinal absorption of glucose, and secondary ketogenesis and lipolysis, which will subsequently affect the functions of the insulin-secreting cells of the pancreas. Evidence showed that thyroid diseases are associated with the development of obesity and metabolic syndrome, and the management for these modalities should involve prior management of underlying thyroid diseases. Efforts should be made to adequately manage these cases with concomitant approaches to achieve the best clinical outcomes.
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Wu D, Xian W, Hong S, Liu B, Xiao H, Li Y. Graves' Disease and Rheumatoid Arthritis: A Bidirectional Mendelian Randomization Study. Front Endocrinol (Lausanne) 2021; 12:702482. [PMID: 34484118 PMCID: PMC8416061 DOI: 10.3389/fendo.2021.702482] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/28/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The frequent coexistence of Graves' disease (GD) and rheumatoid arthritis (RA) has been cited and discussed in observational studies, but it remains a question as to whether there is a causal effect between the two diseases. METHODS We retrieved genome-wide association study (GWAS) summary data of GD and RA from BioBank Japan (BBJ). Single nucleotide polymorphisms (SNPs) associated with diseases of interest were selected as instrumental variables (IVs) at a genome-wide significance level (P < 5.0 × 10-8). The random-effects inverse variance weighted method (IVW) was used to combine the causal effect of IVs. The horizontal pleiotropy effect was analyzed by MR-Egger and weighted median method sensitivity test. A leave-one-out analysis was conducted to avoid bias caused by a single SNP. The statistical power of our MR result was calculated according to Brion's method. RESULTS Our study discovered a bidirectional causal effect between GD and RA. The presence of RA may increase the risk of GD by 39% (OR 1.39, 95% CI 1.10-1.75, P = 0.007). Similarly, the existence of GD may increase the risk of RA by 30% (OR 1.30, 95% CI 0.94-1.80, P = 0.112). Our study provides 100% power to detect the causal effect of RA on GD risk, and vice versa. CONCLUSIONS We found a bidirectional causal effect between GD and RA in an Asian population. Our study supported the clinical need for screening GD in RA patients, and vice versa. The potential benefit of sound management of RA in GD patients (or GD in RA patients) merits excellent attention. Moreover, novel satisfactory medicine for RA may be applicable to GD and such potential is worthy of further investigation.
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Ataca Atilla P, Akkus E, Atilla E, Gokmen N, Civriz Bozdag S, Kurt Yuksel M, Toprak SK, Baskal N, Akan H, Demirer T, Topcuoglu P, Arslan O, Ilhan O, Ozcan M, Beksac M, Gurman G. Thyroid dysfunctions in adult patients after allogeneic hematopoietic stem cell transplantation. Clin Transplant 2020; 34:e14049. [PMID: 32713042 DOI: 10.1111/ctr.14049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 07/20/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Thyroid dysfunction (TD) is one of the major endocrinopathies shown after allogeneic hematopoietic stem cell transplantation over the long term. The incidence and the risk factors for TD have varied widely. PATIENTS AND METHODS Two hundred and fifty-nine patients with pre-transplant normal thyroid function tests who survived at least 1 year after allo-HSCT between 2006-2016 were included in the study. RESULTS Sixty-four patients (25%) developed TD at median of 34 months (range, 1-112 months). Hypothyroidism was detected in 32 patients (12%): 5 patients had primary hypothyroidism, and subclinical hypothyroidism occurred in 27 patients. 18 patients (7%) were diagnosed with hyperthyroidism: 2 patients (0.07%) were treated for primary hyperthyroidism, and 16 patients (6%) were followed for subclinical hyperthyroidism. Euthyroid sick syndrome occurred in 14 cases. None of the patients with thyroid dysfunction developed secondary thyroid malignancy. Receiving high-dose TBI (P = .001) was found to be significant risk for hypothyroidism; older age than median (P = .01) and pre-transplant active disease (P < .0001) were related to hyperthyroidism. CONCLUSIONS Thyroid dysfunction, mostly hypothyroidism, is a long-term complication after allo-HSCT in 25% of patients. Older age, pre-transplant active disease, and receiving TBI are among the risk factors. Sustained long-term monitoring of thyroid function test should be considered post allo-HSCT.
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Affiliation(s)
- Pinar Ataca Atilla
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Erman Akkus
- Department of Internal Medicine, Ankara University School of Medicine, Ankara, Turkey
| | - Erden Atilla
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Neslihan Gokmen
- Department of Basic Sciences, Istanbul Technical University, Istanbul, Turkey
| | - Sinem Civriz Bozdag
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Meltem Kurt Yuksel
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Selami Kocak Toprak
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Nilgun Baskal
- Department of Endocrinology, Ankara University School of Medicine, Ankara, Turkey
| | - Hamdi Akan
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Taner Demirer
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Pervin Topcuoglu
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Onder Arslan
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Osman Ilhan
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Muhit Ozcan
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Meral Beksac
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Gunhan Gurman
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
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