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Bruggmann, P., T. Berg, A. L. H. Øvrehus, C. Moreno, C. E. Brandão Mello, F. Roudot-Thoraval, R. T. Marinho, M. Sherman, S. D. Ryder, J. Sperl et al. "Historical epidemiology of hepatitis C virus (HCV) in selected countries." Journal of viral hepatitis 21 Suppl 1 (2014): 5-33. Abstract

Chronic infection with hepatitis C virus (HCV) is a leading indicator for liver disease. New treatment options are becoming available, and there is a need to characterize the epidemiology and disease burden of HCV. Data for prevalence, viremia, genotype, diagnosis and treatment were obtained through literature searches and expert consensus for 16 countries. For some countries, data from centralized registries were used to estimate diagnosis and treatment rates. Data for the number of liver transplants and the proportion attributable to HCV were obtained from centralized databases. Viremic prevalence estimates varied widely between countries, ranging from 0.3% in Austria, England and Germany to 8.5% in Egypt. The largest viremic populations were in Egypt, with 6,358,000 cases in 2008 and Brazil with 2,106,000 cases in 2007. The age distribution of cases differed between countries. In most countries, prevalence rates were higher among males, reflecting higher rates of injection drug use. Diagnosis, treatment and transplant levels also differed considerably between countries. Reliable estimates characterizing HCV-infected populations are critical for addressing HCV-related morbidity and mortality. There is a need to quantify the burden of chronic HCV infection at the national level.

Razavi, H., I. Waked, C. Sarrazin, R. P. Myers, R. Idilman, F. Calinas, W. Vogel, M. C. Mendes Correa, C. Hézode, P. Lázaro et al. "The present and future disease burden of hepatitis C virus (HCV) infection with today's treatment paradigm." Journal of viral hepatitis 21 Suppl 1 (2014): 34-59. Abstract

The disease burden of hepatitis C virus (HCV) is expected to increase as the infected population ages. A modelling approach was used to estimate the total number of viremic infections, diagnosed, treated and new infections in 2013. In addition, the model was used to estimate the change in the total number of HCV infections, the disease progression and mortality in 2013-2030. Finally, expert panel consensus was used to capture current treatment practices in each country. Using today's treatment paradigm, the total number of HCV infections is projected to decline or remain flat in all countries studied. However, in the same time period, the number of individuals with late-stage liver disease is projected to increase. This study concluded that the current treatment rate and efficacy are not sufficient to manage the disease burden of HCV. Thus, alternative strategies are required to keep the number of HCV individuals with advanced liver disease and liver-related deaths from increasing.

Wedemeyer, H., A. S. Duberg, M. Buti, W. M. Rosenberg, S. Frankova, G. Esmat, N. Örmeci, H. Van Vlierberghe, M. Gschwantler, U. Akarca et al. "Strategies to manage hepatitis C virus (HCV) disease burden." Journal of viral hepatitis 21 Suppl 1 (2014): 60-89. Abstract

The number of hepatitis C virus (HCV) infections is projected to decline while those with advanced liver disease will increase. A modeling approach was used to forecast two treatment scenarios: (i) the impact of increased treatment efficacy while keeping the number of treated patients constant and (ii) increasing efficacy and treatment rate. This analysis suggests that successful diagnosis and treatment of a small proportion of patients can contribute significantly to the reduction of disease burden in the countries studied. The largest reduction in HCV-related morbidity and mortality occurs when increased treatment is combined with higher efficacy therapies, generally in combination with increased diagnosis. With a treatment rate of approximately 10%, this analysis suggests it is possible to achieve elimination of HCV (defined as a >90% decline in total infections by 2030). However, for most countries presented, this will require a 3-5 fold increase in diagnosis and/or treatment. Thus, building the public health and clinical provider capacity for improved diagnosis and treatment will be critical.

Umar, Muhammed, Aamir G. Khan, Zaigham Abbas, Sanjeev Arora, Naqvi Asifabbas, Andre Elewaut, Gamal Esmat, Graham Foster, Michael Fried, Khean-L Goh et al. "World Gastroenterology Organisation global guidelines: diagnosis, management and prevention of hepatitis C April 2013." Journal of clinical gastroenterology 48, no. 3 (2014): 204-17. Abstract
Waked, Imam, Waheed Doss, Manal Hamdy El-Sayed, Chris Estes, Homie Razavi, Gamal Shiha, Ayman Yosry, and Gamal Esmat. "The current and future disease burden of chronic hepatitis C virus infection in Egypt." Arab journal of gastroenterology : the official publication of the Pan-Arab Association of Gastroenterology 15, no. 2 (2014): 45-52. Abstract
Bonnard, P., A. Elsharkawy, K. Zalata, E. Delarocque-Astagneau, L. Biard, L. Le Fouler, A. B. Hassan, M. Abdel-Hamid, M. El-Daly, M. E. Gamal et al. "Comparison of liver biopsy and noninvasive techniques for liver fibrosis assessment in patients infected with HCV-genotype 4 in Egypt." Journal of viral hepatitis (2014). Abstract

In Egypt, as elsewhere, liver biopsy (LB) remains the gold standard to assess liver fibrosis in chronic hepatitis C (CHC) and is required to decide whether a treatment should be proposed. Many of its disadvantages have led to develop noninvasive methods to replace LB. These new methods should be evaluated in Egypt, where circulating virus genotype 4 (G4), increased body mass index and co-infection with schistosomiasis may interfere with liver fibrosis assessment. Egyptian CHC-infected patients with G4 underwent a LB, an elastometry measurement (Fibroscan(©) ), and serum markers (APRI, Fib4 and Fibrotest(©) ). Patients had to have a LB ≥15 mm length or ≥10 portal tracts with two pathologists blinded readings to be included in the analysis. Patients with hepatitis B virus co-infection were excluded. Three hundred and twelve patients are reported. The performance of each technique for distinguishing F0F1 vs F2F3F4 was compared. The area under receiver operating characteristic curves was 0.70, 0.76, 0.71 and 0.75 for APRI, Fib-4, Fibrotest© and Fibroscan©, respectively (no influence of schistosomiasis was noticed). An algorithm using the Fib4 for identifying patients with F2 stage or more reduced by nearly 90% the number of liver biopsies. Our results demonstrated that noninvasive techniques were feasible in Egypt, for CHC G4-infected patients. Because of its validity and its easiness to perform, we believe that Fib4 may be used to assess the F2 threshold, which decides whether treatment should be proposed or delayed.

Hézode, Christophe, Gideon M. Hirschfield, Wayne Ghesquiere, William Sievert, Maribel Rodriguez-Torres, Stephen D. Shafran, Paul J. Thuluvath, Harvey A. Tatum, Imam Waked, Gamal Esmat et al. "Daclatasvir plus peginterferon alfa and ribavirin for treatment-naive chronic hepatitis C genotype 1 or 4 infection: a randomised study." Gut (2014). Abstract

OBJECTIVE: To evaluate the safety and efficacy of daclatasvir, an HCV NS5A inhibitor with pangenotypic activity, administered with peginterferon-alfa-2a/ribavirin.

DESIGN: In this Phase 2b double-blind, placebo-controlled study, treatment-naive adults with HCV genotype 1 (N=365) or 4 (N=30) infection were randomly assigned (2:2:1) to daclatasvir 20 mg or 60 mg, or placebo once daily plus weekly peginterferon-alfa-2a and twice-daily ribavirin. Daclatasvir recipients achieving protocol-defined response (PDR; HCV-RNA

Alboraie, Mohamed, Marwa Khairy, Marwa Elsharkawy, Noha Asem, Aisha Elsharkawy, and Gamal Esmat. "Value of Egy-Score in diagnosis of significant, advanced hepatic fibrosis and cirrhosis compared to aspartate aminotransferase-to-platelet ratio index, FIB-4 and Forns' index in chronic hepatitis C virus." Hepatology research : the official journal of the Japan Society of Hepatology (2014). Abstract

AIM: Serum markers and developed scores are of rising importance in non-invasive diagnosis of hepatic fibrosis. Aspartate aminotransferase-to-platelet ratio index (APRI), FIB-4 and Forns' index are validated scores used for diagnosis of liver fibrosis. The Egy-Score is a newly developed score for detection of hepatic fibrosis with promising results. We aimed to assess the accuracy of the Egy-Score in the diagnosis of significant fibrosis, advanced fibrosis and cirrhosis compared to APRI, FIB-4 and Forns' in chronic hepatitis C virus (HCV) patients.

METHODS: A retrospective study including 100 chronic hepatitis C naïve Egyptian patients was performed. Patients were classified according to stages of fibrosis into three groups: significant fibrosis (≥ F2), advanced fibrosis (≥ F3) and cirrhosis (F4). Egy-Score, APRI, FIB-4 and Forns' index were calculated. Regression analysis and receiver-operator curves were plotted to assess the sensitivity, specificity and predictive values for the significant scores with the best cut-off for diagnosis.

RESULTS: An Egy-Score of 3.28 or more was superior to APRI, FIB-4 and Forns' index for detecting advanced fibrosis with a sensitivity of 91% and specificity of 78%. An Egy-Score of 3.67 or more was superior to APRI, FIB-4 and Forns' index for detecting cirrhosis with a sensitivity of 82% and specificity of 87%. Forns' index was superior to Egy-Score, FIB-4 and APRI for detecting significant fibrosis.

CONCLUSION: The Egy-Score is a promising, accurate, easily calculated, cost-effective score in the prediction of hepatic fibrosis in chronic HCV patients with superiority over APRI, FIB-4 and Forns' index in advanced hepatic fibrosis and cirrhosis.

Esmat, Gamal, Maissa El Raziky, Aisha Elsharkawy, Dina Sabry, Mohamed Hassany, Amal Ahmed, Noha Assem, Mohamad El Kassas, and Wahid Doss. "Impact of Vitamin D Supplementation on Sustained Virological Response in Chronic Hepatitis C Genotype 4 Patients Treated by Pegylated Interferon/Ribavirin." Journal of interferon & cytokine research : the official journal of the International Society for Interferon and Cytokine Research (2014). Abstract

The current standard of care therapy (SOC) for chronic HCV is pegylated interferon/ribavirin (Peg-IFN/RBV). Many reports showed the possible role of vitamin D supplementation in augmenting the response to SOC. The aim of this study was to assess the role of vitamin D supplementation on the response to treatment in chronic HCV genotype 4 patients. One hundred and one chronic HCV patients were classified into two groups (Group 1): 51 patients received the SOC therapy consisting of Peg-interferon alfa-2b plus ribavirin, (Group 2): 50 patients received the SOC therapy+vitamin D3 (Cholecalciferol) in a dose of 15,000 IU/week during the treatment course. Vitamin D deficiency was found in 95% of patients. No correlation was found between vitamin D levels and stage of fibrosis in the whole population. Vitamin D supplementation had no positive impact on treatment outcome where sustained virological response (SVR) was achieved in 51.2% in group 2 and 71.4% in group 1 by per-protocol analysis and in 44% in group 2 and in 68.6% in group 1 by intention to treat analysis (P value 0.22 and 0.220 respectively). Despite its role in other genotypes, vitamin D supplementation has no significant impact on SVR in HCV Genotype 4 patient. No correlation was found between vitamin D levels and stage of liver fibrosis.

Fawzy, Injie O., Mohamed Negm, Rasha Ahmed, Gamal Esmat, Nabila Hamdi, and Ahmed I. Abdelaziz. "Tamoxifen downregulates MxA expression by suppressing TLR7 expression in PBMCs of males infected with HCV." Journal of medical virology 86, no. 7 (2014): 1113-9. Abstract

Gender discrepancies in immune response to HCV infections and during HCV therapy exist and previous findings including those from this research team indicate the female sex hormone, 17β-estradiol (E2), to be one probable cause of such inconsistencies. Also, it was recently demonstrated that estrogen receptor modulator Tamoxifen (TAM) exerts an upmodulating/enhancing effect on the TLR7 and JAK-STAT pathways in PBMCs of premenopausal females infected with HCV. Pursuing this work, a discrepancy was noticed in the results from male patients, therefore this study aimed to determine whether the effects of TAM previously observed in the PBMCs of women would hold true in PBMCs from males infected with HCV. Isolated PBMCs were pooled and relative expression of the TLR7 was quantified using RTqPCR. Sets of PBMCs were treated with exogenous interferon alpha (IFNα) or the TLR7 ligand, Imiquimod; these stimulations were performed with and without E2 and TAM pretreatment and the relative gene expressions of TLR7 and MxA were measured. Pretreatment with E2 and IFNα downregulated TLR7 (**P = 0.0080) and TAM further decreased this expression significantly (*P = 0.0284). TAM pretreatment also caused a significant downregulation in MxA expression in Imiquimod-stimulated PBMCs (*P = 0.0218). In conclusion, TAM displays several paradoxical effects in PBMCs of males infected with HCV compared to those of females. Contrary to the previous study involving premenopausal females, in PBMCs of infected males TAM may decrease IFNα release as indicated by reduced MxA expression possibly via the suppression of TLR7 expression.

Esmat, Gamal, Mohamed El Kassas, Mohamed Hassany, Mohamed Gamil, and Maissa El Raziky. "Optimizing treatment for HCV genotype 4: PEG-IFN alfa 2a vs. PEG-IFN alfa 2b; the debate continues." Liver international : official journal of the International Association for the Study of the Liver 34 Suppl 1 (2014): 24-8. Abstract

Hepatitis C virus (HCV) remains one of the leading causes of morbidity and mortality worldwide. Combined therapy with pegylated interferon (PEG-IFN) and ribavirin is the current standard of care treatment for HCV genotype 4. Two types of PEG-IFN are commercially available. The limited number of trials that were conducted for HCV genotype 4 and the few head to head comparisons make it impossible to know which is the best option? In this article we review all available PEG-IFN trials performed worldwide for HCV genotype 4 since 2004. Unless another molecule is developed as a standalone for the treatment of HCV, PEG-IFN will continue to be a source of debate.

Shehab, H., I. Elattar, T. Elbaz, M. Mohey, and G. Esmat. "CUFA algorithm: assessment of liver fibrosis using routine laboratory data." Journal of viral hepatitis 21, no. 12 (2014): 956-64. Abstract

Staging of liver fibrosis is an integral part of the management of HCV. Liver biopsy is hampered by its invasiveness and possibility of sampling error. Current noninvasive methods are disadvantaged by their cost and complexity. In this study, we aimed at developing a noninvasive method for the staging of liver fibrosis based only on routine laboratory tests and clinical data. Basic clinical and laboratory data and liver biopsies were collected from 994 patients presenting for the evaluation of HCV. Logistic regression was used to create a model predictive of fibrosis stages. A sequential test was then developed by combining our new model with APRI. In the training set (497) a model was created by logistic regression for the prediction of significant fibrosis (≥F2), it included platelets, AST and age (PLASA). The areas under the curve (AUC), sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 0.753, 66.8, 71.4, 69.8, 68.4, respectively, while in the validation set (497), they were 0.777, 66.7, 72.8, 68.6 and 71, respectively. These were the best performance indicators when compared to APRI, FIB-4, King's score, platelets, fibrosis index, age-platelet index and Lok index in the same set of patients. A sequential test was then developed including APRI followed by PLASA [Cairo University Fibrosis Assessment (CUFA) algorithm], this allowed saving 20% and 34% of liver biopsies for patients being tested for significant fibrosis and cirrhosis, respectively. In conclusion, the CUFA algorithms at no cost allow saving a significant proportion of patients from performing a liver biopsy or a more complex costly test. These algorithms could be used as the first step in the assessment of liver fibrosis before embarking on the more costly advanced serum markers, Fibroscan or liver biopsy.

Obach, Dorothée, Sylvie Deuffic-Burban, Gamal Esmat, Wagida A. Anwar, Sahar Dewedar, Valérie Canva, Anthony Cousien, Wahid Doss, Aya Mostafa, Stanislas Pol et al. "Effectiveness and cost-effectiveness of immediate versus delayed treatment of hepatitis C virus-infected patients in a country with limited resources: the case of Egypt." Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 58, no. 8 (2014): 1064-71. Abstract

BACKGROUND: Because of logistical and economic issues, in Egypt, as in other resource-limited settings, decision makers should determine for which patients hepatitis C virus (HCV) treatment should be prioritized. We assessed the effectiveness and cost-effectiveness of different treatment initiation strategies.

METHODS: Using a Markov model, we simulated HCV disease in chronically infected patients in Egypt, to compare lifetime costs, quality-adjusted life expectancy (QALE), and the incremental cost-effectiveness ratio (ICER) of different treatment initiation strategies.

RESULTS: Immediate treatment of patients at stages F1/F2/F3 was less expensive and more effective than delaying treatment until more severe stages or not providing treatment (in patients diagnosed at F1: QALE = 18.32 years if treatment at F1 vs 18.22 if treatment at F2). Treatment of F4 patients was more effective than no treatment at all (QALE = 10.33 years vs 8.77 years) and was cost-effective (ICER = $1915/quality-adjusted life-year [QALY]). When considering that affordable triple therapies, including new direct-acting antivirals, will be available starting in 2016, delaying treatment until stage F2, then treating all patients regardless of their disease stage after 2016, was found to be cost-effective (ICER = $33/QALY).

CONCLUSIONS: In Egypt, immediate treatment of patients with fibrosis stage F1-F3 who present to care is less expensive and more effective than delaying treatment. However, immediate treatment at stage F1 is only slightly more effective than waiting for disease to progress to stage F2 before starting treatment and is sensitive to the forthcoming availability of new treatments. Treating patients at stage F4 is highly effective and cost-effective. In Egypt, decision makers should prioritize treatment for F4 patients and delay treatment for F1 patients who present to care.

Cousien, Anthony, Dorothée Obach, Sylvie Deuffic-Burban, Aya Mostafa, Gamal Esmat, Valérie Canva, Mohamed El Kassas, Mohammad El-Sayed, Wagida A. Anwar, Arnaud Fontanet et al. "Is expert opinion reliable when estimating transition probabilities? The case of HCV-related cirrhosis in Egypt." BMC medical research methodology 14 (2014): 39. Abstract

BACKGROUND: Data on HCV-related cirrhosis progression are scarce in developing countries in general, and in Egypt in particular. The objective of this study was to estimate the probability of death and transition between different health stages of HCV (compensated cirrhosis, decompensated cirrhosis and hepatocellular carcinoma) for an Egyptian population of patients with HCV-related cirrhosis.

METHODS: We used the "elicitation of expert opinions" method to obtain collective knowledge from a panel of 23 Egyptian experts (among whom 17 were hepatologists or gastroenterologists and 2 were infectiologists). The questionnaire was based on virtual medical cases and asked the experts to assess probability of death or probability of various cirrhosis complications. The design was a Delphi study: we attempted to obtain a consensus between experts via a series of questionnaires interspersed with group response feedback.

RESULTS: We found substantial disparity between experts' answers, and no consensus was reached at the end of the process. Moreover, we obtained high death probability and high risk of hepatocellular carcinoma. The annual transition probability to death was estimated at between 10.1% and 61.5% and the annual probability of occurrence of hepatocellular carcinoma was estimated at between 16.8% and 58.9% (depending on age, gender, time spent in cirrhosis and cirrhosis severity).

CONCLUSIONS: Our results show that eliciting expert opinions is not suited for determining the natural history of diseases due to practitioners' difficulties in evaluating quantities. Cognitive bias occurring during this type of study might explain our results.

Ismail, Sohair, Hanan Abdel Hafez, Samar K. Darweesh, Kamal Hassan Kamal, and Gamal Esmat. "Virologic response and breakthrough in chronic hepatitis B Egyptian patients receiving lamivudine therapy." Annals of gastroenterology : quarterly publication of the Hellenic Society of Gastroenterology 27, no. 4 (2014): 380-386. Abstract

BACKGROUND: Lamivudine monotherapy is effective in suppressing hepatitis B virus (HBV) replication to undetectable levels by PCR, in ameliorating liver disease and to some extent in achieving HBsAg seroconversion. This study aimed at assessing the virological and biochemical responses as well as breakthrough in HBeAg-negative chronic HBV (CHB) Egyptian patients receiving lamivudine therapy.

METHODS: This retrospective study included 140 CHB patients with positive serum HBV-DNA by quantitative PCR assays and negative HBeAg who had never received prior anti-viral therapy for HBV. According to duration of lamivudine therapy (100 mg/day) patients were grouped into: group I (n=59) who received lamivudine for 1 year, group II (n=50) who received lamivudine for 2 years, and group III (n=31) who received lamivudine for 3 years.

RESULTS: In group I, 76.3% patients had virologic response but this was reduced in group II and group III to 72% and 67.7% respectively. None of the patients in group I developed virologic breakthrough, whereas 12% and 25.8% in groups II and III respectively developed breakthrough. In group I, 25% of patients having high pre-treatment viremia showed virologic response compared to 84.6% and 83.3% having mild and moderate viremia respectively (P<0.01). However, in groups II and III, there was no significant relationship between pre-treatment viremia and virologic response. No significant relationship was found between pre-treatment viral load and incidence of breakthrough within each group.

CONCLUSION: Lamivudine remains one of the antiviral therapies for HBeAg negative CHB patients. The rates of maintained virologic and biochemical responses to lamivudine decrease in time due to selection of drug-resistant mutants and, hence, breakthrough.

Breban, R., W. Doss, G. Esmat, M. Elsayed, M. Hellard, P. Ayscue, M. Albert, A. Fontanet, and M. K. Mohamed. "Quantifying current hepatitis C virus incidence in Egypt - Response to letter by Miller and Abu-Raddad." JOURNAL OF VIRAL HEPATITIS 20 (2013): 668. Abstract
Hatzakis, P. Van Damme, K. Alcorn, C. Gore, M. Benazzouz, S. Berkane, M. Buti, M. Carballo, Cortes H. Martins, S. Deuffic-Burban et al. "The State of Hepatitis B and C in the Mediterranean and Balkan Countries: Report from a Summit Conference (vol 20, pg 1, 2013)." JOURNAL OF VIRAL HEPATITIS 20 (2013): 744. Abstract
Abdel-Rahman, Mahasen, Yasmin Saad, Maissa El-Raziky, Naglaa Zayed, Wafaa El-Akel, Mohamed Said, Mohamed El-Beshlawy, and Gamal Esmat. "Hepatitis C genotype 4 with normal transaminases: Correlation with fibrosis and response to treatment, a cohort Egyptian study of 4277 patients." CLINICS AND RESEARCH IN HEPATOLOGY AND GASTROENTEROLOGY 37 (2013): 479-484. Abstract
Khairy, Marwa, Maissa El-Raziky, Wafaa El-Akel, Mohamed S. Abdelbary, Hany Khatab, Badawy El-Kholy, Gamal Esmat, and Mahassen Mabrouk. "Serum autoantibodies positivity prevalence in patients with chronic HCV and impact on pegylated interferon and ribavirin treatment response." LIVER INTERNATIONAL 33 (2013): 1504-1509. Abstract
Abdel-Rahman, Mahasen, Mohammad El-Sayed, Maissa El Raziky, Aisha Elsharkawy, Wafaa El-Akel, Hossam Ghoneim, Hany Khattab, and Gamal Esmat. "Coinfection with hepatitis C virus and schistosomiasis: Fibrosis and treatment response." WORLD JOURNAL OF GASTROENTEROLOGY 19 (2013): 2691-2696. Abstract
El Tayebi, H. M., K. Omar, S. Hegy, M. El Maghrabi, M. El Brolosy, K. A. Hosny, G. Esmat, and A. I. Abdelaziz. "Repression of miR-17-5p with elevated expression of E2F-1 and c-MYC in non-metastatic hepatocellular carcinoma and enhancement of cell growth upon reversing this expression pattern." BIOCHEMICAL AND BIOPHYSICAL RESEARCH COMMUNICATIONS 434 (2013): 421-427. Abstract
Raziky, Maissa El, Waleed Fouad Fathalah, Wafaa Ahmed El-akel, Ahmed Salama, Gamal Esmat, Mahassen Mabrouk, Rabab Mamoun Salama, and Hany Mahmoud Khatab. "The Effect of Peginterferon Alpha-2a vs. Peginterferon Alpha-2b in Treatment of Naive Chronic HCV Genotype-4 Patients: A Single Centre Egyptian Study." HEPATITIS MONTHLY 13 (2013). Abstract
El-Kady, Nabeel M., Gamal Esmat, Ekram H. Mahmoud, Samar K. Darweesh, Sherif H. Mahmoud, and Waleed A. Elagawy. "Hypertonic saline-enhanced radiofrequency versus chemoembolization sequential radiofrequency in the treatment of large hepatocellular carcinoma." EUROPEAN JOURNAL OF GASTROENTEROLOGY & HEPATOLOGY 25 (2013): 628-633. Abstract
Esmat, Gamal. "Hepatitis C in the Eastern Mediterranean Region." EASTERN MEDITERRANEAN HEALTH JOURNAL 19 (2013): 587-588. Abstract
Elalfy, Mohsen S., Gamal Esmat, Randa M. Matter, Hesham Abdel E. Aziz, and Walid A. Massoud. "Liver fibrosis in young Egyptian beta-thalassemia major patients: relation to hepatitis C virus and compliance with chelation." ANNALS OF HEPATOLOGY 12 (2013): 54-61. Abstract