- Hepatitis is inflammation of the liver that can be caused by infectious viruses or noninfectious agents. There are different types classified as A, B, C, D, and E. Some types are preventable through vaccination.
- Hepatitis has a variety of presentations ranging from no symptoms to severe liver failure. Chronic hepatitis can cause liver damage including cirrhosis and liver cancer.
- Treatment depends on the type and severity of hepatitis. It may involve antiviral medications, immunosuppressants, supportive care, or liver transplantation in severe cases. Vaccines exist for hepatitis A, B, and E and can prevent infection and complications.
world hepatitis day awareness presentation july 2022.pptxanjalatchi
World Hepatitis Day (WHD) is recognized annually on July 28th, the birthday of Dr. Baruch Blumberg (1925–2011). Dr. Blumberg discovered the hepatitis B virus in 1967, and 2 years later he developed the first hepatitis B vaccine
Guía práctica de Hepatitis C 2011
Journal of Hepatology
EASL (European Association for the study of the Liver)
MEDICINA CORDOBA WEB
www.plan93.com
www.medicinacordoba.com.ar
world hepatitis day awareness presentation july 2022.pptxanjalatchi
World Hepatitis Day (WHD) is recognized annually on July 28th, the birthday of Dr. Baruch Blumberg (1925–2011). Dr. Blumberg discovered the hepatitis B virus in 1967, and 2 years later he developed the first hepatitis B vaccine
Guía práctica de Hepatitis C 2011
Journal of Hepatology
EASL (European Association for the study of the Liver)
MEDICINA CORDOBA WEB
www.plan93.com
www.medicinacordoba.com.ar
Hepatitis is generally refer to inflammation of liver, it is resulted from infectious causes (such as viral, bacterial and fungal causes ) or noninfectious ( such as alcohol drugs, autoimmune diseases and metabolic diseases) , in this research , I’m going to focus on viral hepatitis because it is the most common cause of acute hepatitis in USA ( 50% of cases ).
The commonness and important viruses that cause viral hepatitis are (A,B,C,D,E) types, approximately 4.4 million Americans are currently living with chronic hepatitis B and C.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Hepatitis is generally refer to inflammation of liver, it is resulted from infectious causes (such as viral, bacterial and fungal causes ) or noninfectious ( such as alcohol drugs, autoimmune diseases and metabolic diseases) , in this research , I’m going to focus on viral hepatitis because it is the most common cause of acute hepatitis in USA ( 50% of cases ).
The commonness and important viruses that cause viral hepatitis are (A,B,C,D,E) types, approximately 4.4 million Americans are currently living with chronic hepatitis B and C.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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2. Objectives:
• To Describe the etiology, epidemiology, pathophysiology of hepatitis.
• To Summarize sign and symptoms of hepatitis.
• To Outline prognosis, treatment and vaccines of hepatitis.
3. Introduction:
Hepatitis is an inflammation and swelling of the liver that is caused by a variety of infectious viruses and
noninfectious agent leading to range of health problems, some of which can be fatal. Some hepatitis factors
might include chemical toxins, poisons, drugs, and alcohol. There are different types of hepatitis, depending
on their modes of transmission, severity of illness, geographical distribution and prevention methods. These
types are classified as: A, B, C, D and E. Some types of hepatitis are preventable through vaccination.
Alcoholic hepatitis is caused by heavy alcohol use. Autoimmune hepatitis is a chronic type in which your
body's immune system attacks your liver [1]
. The cause is not known, but genetics and your environment
may play a role. Hepatitis can be further classified into acute and chronic based on the duration of the
inflammation/insult to the liver. If inflammation of the liver lasts for less than 6 months, then it is termed
as acute hepatitis and if it lasts longer than 6 months it is termed as chronic hepatitis. Acute hepatitis is
usually self-resolving but can cause fulminant liver failure depending on the etiology. In contrast, chronic
hepatitis can cause liver damage that includes liver fibrosis, cirrhosis, hepatocellular carcinoma, and
features of portal hypertension leading to significant morbidity and mortality [2,3]
. In particular , types B
and C lead to chronic disease in hundreds of millions of people and together are the most common cause
of liver cirrhosis, liver cancer and viral hepatitis-related deaths [4].
4. Etiology:
Viral hepatitis
Viral hepatitis results from infection with viruses A, B, C, D, and E. Hepatitis A is a picornavirus most
commonly transmitted through the oral-fecal route via exposure to contaminated food with greater viral load
shedding occurring during the end of the incubation period. According to the World Health Organization
(WHO),
infection rates in developed countries are low. However, high-risk groups include injection-drug users, men
who have sex with men, people traveling to endemic areas, and isolated communities[4]
. Hepatitis B on the
other hand is
[5]
.
a
member
of
the hepadnavirus
family
Unlike
type
A
the
virus
particle
(virion)
consists
of
an
outer lipid envelope and an icosahedral nucleocapsid core composed of core protein. Hepatitis B virus is
known to have eight genotype variants of no practical use to determine severity. Hepatitis B virus can be
detected in serum, semen, vaginal mucus, saliva, and tears even at a lower level but not found in the stool,
urine, or sweat. The virus can be transmitted parenterally and to less extent sexually. Intravenous drug
users, healthcare workers with exposure to infected body fluids, patients who require frequent and multiple
blood transfusions, prisoners, partners of hepatitis B virus carriers, and persons born in endemic areas are
all at high risk for hepatitis B virus infection. The virus can be transmitted perinatal also, and it occurs in
infants of HBeAg positive women where the infants would have a 70% to 90% chance of infection and may
end up having cirrhosis[5]
. The hepatitis C virus (HCV) is a small, enveloped, single-stranded, positive-sense
RNA virus [6]
. It is a member of the genus Hepacivirus in the family Flaviviridae. There are seven major
genotypes of HCV. Transmission Percutaneous contact with contaminated blood is responsible for most
infections [7]
.
5. Autoimmune Hepatitis
The exact etiology of autoimmune hepatitis is unknown. Various factors like drugs, environmental agents, or viral
infection with hepatitis C viruses or Epstein-Barr virus may trigger an autoimmune response. Drugs like nitrofurantoin,
minocycline, adalimumab, infliximab, or methyldopa can trigger autoimmune hepatitis [9]
.
Alcoholic Hepatitis
The exact mechanism of how alcoholic hepatitis is not well defined; many factors play a role that includes genetic
factors, metabolism of ethanol and its metabolite acetaldehyde causing damage to hepatocyte cell membranes [10]
.
Epidemiology:
Viral Hepatitis
Viral Hepatitis is considered a major public health issue. starting with type A virus affects 90% of children in high
endemic regions[11]
. and are commonly associated with poor sanitary conditions like water contamination and inadequate
sewage disposal in both developing and developed countries [12]
. Children who get infected at an early age with
asymptomatic exposure end up acquiring lifelong immunity in highly endemic countries [13]
. In the US, approximately
24,900 new infections are diagnosed each year. Chronic Hepatitis B and C infection can cause liver damage that includes
liver fibrosis, cirrhosis, hepatocellular carcinoma, and features of portal hypertension. The World Health Organization
(WHO) estimated that 1.3 million people have died due to hepatitis in 2015, and 1 in 3
6. people in the world have had infections with either hepatitis B or hepatitis C virus. Reportedly, infection
rates show that 2 billion people infected with the hepatitis B virus, 185 million with the hepatitis C virus
(most commonly being affected are IV drug users and hemophiliacs), and 20 million with the hepatitis E
virus [11,12,13]
. Viral hepatitis ends up causing 1.4 million deaths annually, and hepatitis B and C viruses are
responsible for about 90% of those deaths. Despite high rates of HBV infection, there are very low rates of
HDV co-infection in other Asian countries, including China [13]
. Regardless of geography, the populations at
highest risk for HDV include people who inject drugs and those with human immunodeficiency virus (HIV)
or HCV [14]
. HDV is even more prevalent in patients with HBV associated cirrhosis and HCV. according to
type E it occur for the same cause as type A but unlike type A hepatitis E virus genotypes 1 and 2 are only
known to infect humans and are highly endemic in developing countries throughout the world[15]
.
Autoimmune Hepatitis
The prevalence of autoimmune hepatitis is estimated to be 0.1 to 1.2 cases per 100000 people in Western
Europe. Autoimmune hepatitis accounts for about 6% of liver transplantation in the United States, while it
accounts for about 3% in Europe. Prevalence in Japan is estimated to be 0.08 to 0.015 cases per 100000
persons and causes 1.9% of cases of liver cirrhosis [16]
.
7. Alcoholic Hepatitis
The precise prevalence of alcoholic hepatitis is unknown, but it is known to be high, with a rising rate of mortality.
It is difficult to assess the correct prevalence as alcoholic hepatitis may remain undiagnosed and completely
asymptomatic [17]
. The prevalence of alcohol use disorder is about 8% of the population of the United States or 16
million people. However, approximately 35% of those with the diagnosis have changes consistent with alcoholic
hepatitis, which means that around 5 million patients may have alcoholic hepatitis[18].
Pathophysiology:
Viral Hepatitis
The incubation period differs according to hepatitis type ranging from 2-6 weeks for type A to 12 weeks for type
B and D while it takes 8 weeks for type C and E [19]
. The time to onset of symptoms may be dose-related. Acute
infections are more severe with higher mortality in adults than children. Relapses are not common. only less than
1% of cases result in fulminant hepatic failure[20]
. Chronic hepatitis is more common (75%) with type C and to less
extent with B type. 30% of hepatitis C even may end up developing cirrhosis with high risk of developing
hepatocellular carcinoma[21]
. D virus results in hepatitis only in persons already having acute or chronic hepatitis
B. Superinfection can result in fulminant hepatic failure [22]
.
8. Autoimmune Hepatitis
Autoimmune hepatitis typically results in high levels of gammaglobulin and circulating autoantibodies. Many
patients have a family history of other autoimmune disorders or had history of immunosuppressive therapy
intake. genetic predisposition may be claimed [23]
.
Alcoholic Hepatitis
The pathogenetic mechanism of alcoholic hepatitis is complex and multifactorial. It results from interactions
between ethanol metabolism, inflammation mediators like cytokines and tumor necrosis factors , and innate
immunity, which end up causing hepatocyte death by necrosis or apoptosis from oxidative stress [24]
.
9. Sign and Symptoms:
Hepatitis has a broad spectrum of presentations that range from a complete lack of symptoms to severe liver
failure [25,26]
. The acute form of hepatitis, generally caused by viral infection, is characterized by constitutional
symptoms that are typically self-limiting[27]
. Chronic hepatitis presents similarly, but can manifest signs and
symptoms specific to liver dysfunction with long-standing inflammation and damage to the organ[28,29]
. The most
common symptoms for viral hepatitis are malaise, fatigue, low-grade fever, anorexia, loss of weight, nausea,
vomiting, etc. Patients can be completely normal on physical exam or may have right upper quadrant pain with
hepatomegaly, urticarial rash and may show signs of dehydration. In advanced stages of liver disease from
chronic viral hepatitis, patients may present with hematemesis, ascites, pedal edema, encephalopathy, etc. [30]
.
These symptoms and signs are observable with many other acute or chronic infectious or non-infectious
conditions. Patients with autoimmune hepatitis and alcoholic hepatitis can also have similar symptoms as in viral
hepatitis, especially when the disease is advanced, and patients experience severe liver dysfunction. A careful
history, laboratory studies, and liver biopsy, when necessary, should be obtained to differentiate them [31]
.
In advanced stages of liver disease from chronic viral hepatitis, patients may present with hematemesis, ascites,
pedal edema, encephalopathy, etc. These symptoms and signs are observable with many other acute or chronic
infectious or non-infectious conditions like viral or bacterial gastroenteritis, acute cholecystitis, acute
cholelithiasis, tuberculosis, HIV, liver abscess, malignancies and peptic ulcer diseases [32]
.
10.
11. Prognosis:
Prognosis of viral hepatitis depends on the virus, causing the infection. with type A infection is usually a mild
self- limiting illness. Patients who infect with this type will develop lifelong immunity against
subsequent infection from hepatitis A and its of low mortality rate. Moving to type B and C patients
will be at risk of developing chronic hepatitis and liver cirrhosis as well as hepatocellular carcinoma as a
consequence [38]
. both type B and C are responsible for a high rate of mortality. type D usually end up with
end stage liver disease and cirrhosis [39]
. Lastly type E unlike type A it causes a high mortality rate in
pregnant patients even though its mechanism still not clear [40]
. On the other hand, the prognosis of
autoimmune hepatitis is directly related to the severity of liver inflammation. Patients who frequently
relapse or do not respond to treatment also have a worse prognosis. 70% of the children diagnosed with
autoimmune hepatitis end up requiring treatment during adulthood. And about 10% of patients require
liver transplantation with low possibility of developing hepatocellular Carcinoma [9]
. for patients who have
alcoholic hepatitis, the prognosis depends on whether they abstain from alcohol and the degree of liver
injury. Various prognostic scoring methods have been developed in the last two decades and include the
discriminant function (DF) model for end-stage liver disease (MELD) score, Glasgow alcoholic hepatitis
score (GAHS), and asymmetric dimethylarginine (ADMA) score [37]
.
12. Treatment:
The treatment of hepatitis varies according to the type, whether it is acute or chronic, and the severity of
the disease. Hepatitis can lead to serious complications if left untreated. There are several treatments
available for hepatitis, depending on the cause and severity of the disease [41]
. One common treatment for
viral hepatitis is antiviral therapy such as interferon and ribavirin these can help to reduce the amount of
virus in the body and improve liver function. In some cases, a combination of antiviral drugs may be used
to treat chronic hepatitis such as with type B and C [42]
. Another approach of treating hepatitis is to focus on
managing the symptoms and complications of the disease. For example, patients with hepatitis may need to
avoid alcohol and certain medications that can further damage the liver. They may also need to make
dietary changes and get regular exercise to improve their overall health. In some cases, more aggressive
treatments may be necessary [43]
. For example, patients with advanced liver disease may require a liver
transplant to replace the damaged liver with a healthy one. However, this is a complex and risky procedure
that is typically reserved for patients with very severe liver damage It is important for patients with
hepatitis to work closely with their healthcare provider to develop a treatment plan that tailored their
individual needs [44]
.
Viral Hepatitis
Here is an overview of the treatment options for different types of hepatitis. according to type A , D and E
Treatment mainly involves supportive care, such as rest, fluids, and pain relievers [45]
. There is no specific
treatment for this type. Moving to type B and C treatment may involve antiviral medications, such as
entecavir ,
13. tenofovir , interferon or direct-acting antivirals (DAAs) which are the main treatment for hepatitis C and can
cure the infection in most cases. In some cases, a liver transplant may be necessary [46]
.
Autoimmune hepatitis
Autoimmune hepatitis is commonly treated by immunosuppressants such as the corticosteroids prednisone
or prednisolone. Treatment of autoimmune hepatitis consists of two phases; an initial and maintenance
phase. The initial phase consists of higher doses of corticosteroids which are tapered down over a number of
weeks to a lower dose [47]
. If used in combination, azathioprine is given during the initial phase as well. Once
the initial phase has been completed, a maintenance phase that consists of lower dose corticosteroids, and in
combination therapy,
Alcoholic hepatitis
First-line treatment of alcoholic hepatitis is treatment of alcoholism.[32]
For those who abstain completely
from alcohol, reversal of liver disease and a longer life are possible [13]
. In addition to referral to
psychotherapy and other treatment programs, treatment should include nutritional and psychosocial
evaluation [49,50]
. Patients should also be treated appropriately for related signs and symptoms, such as
ascites, hepatic encephalopathy, and infection. Severe alcoholic hepatitis has a poor prognosis and is
notoriously difficult to treat [51]
. Without any treatment, 20-50% of patients may die within a month, but
evidence shows treatment may extend life beyond one
[52,53]
.
month
Available treatment options include pentoxifylline, which is a nonspecific TNF inhibitor,
corticosteroids, such as prednisone, corticosteroids with N-acetylcysteine , and corticosteroids with pentoxifylline
14. Vaccines:
Vaccines are available for hepatitis A, B, and E. Hepatitis
A vaccine is highly effective and provides long-term
immunity with one or two doses. Combination vaccines
for hepatitis A and B are available, and are
recommended for individuals at risk of both infections
[53]
. Hepatitis E vaccine is available in some countries, but
its efficacy and long-term protection is still under
investigation. Vaccination is the most effective way to
prevent hepatitis and its complications [54]
. Hepatitis
vaccination is recommended for individuals at high risk
of infection, such as healthcare workers, travelers to
endemic areas, individuals with chronic liver disease, and
people who engage in high-risk behaviors. Vaccine safety
and efficacy are continually monitored through post-
marketing surveillance and clinical trials [55]
.
15. Conclusions:
Hepatitis is inflammation of the liver tissue. Some people or animals with hepatitis have no symptoms,
whereas others develop yellow discoloration of the skin and whites of the eyes (jaundice), poor appetite,
vomiting, tiredness, abdominal pain, and diarrhea. Hepatitis is acute if it resolves within six months, and
chronic if it lasts longer than six months. Acute hepatitis can resolve on its own, progress to chronic hepatitis,
or (rarely) result in acute liver failure. Chronic hepatitis may progress to scarring of the liver (cirrhosis),
liver failure, and liver cancer. Hepatitis is most commonly caused by the viruses hepatitis A, B, C, D, and E.
Other causes include heavy alcohol use, certain medications, toxins, other infections, autoimmune diseases,
and non-alcoholic steatohepatitis (NASH). Hepatitis A and E are mainly spread by contaminated food and
water. Hepatitis B is mainly sexually transmitted, but may also be passed from mother to baby during
pregnancy or childbirth and spread through infected blood. Hepatitis C is commonly spread through
infected blood such as may occur during needle sharing by intravenous drug users. Hepatitis D can only
infect people already infected with hepatitis B. Hepatitis A, B, and D are preventable with immunization.
Medications may be used to treat chronic viral hepatitis. Antiviral medications are recommended in all with
chronic hepatitis C, except those with conditions that limit their life expectancy. There is no specific
treatment for NASH; however, physical activity, a healthy diet, and weight loss are recommended.
Autoimmune hepatitis may be treated with medications to suppress the immune system. A liver transplant
may be an option in both acute and chronic liver failure.
16. REFERENCES
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