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JSM Clinical Case Reports

Evolution of Quality of Life in Patients with Anaphylaxis Due to LTP Syndrome After 3 Years of Specific Immunotherapy and 1 Year after Treatment Completion

Case Report | Open Access

  • 1. Reina Sofia University General Hospital, Allergology Section, Spain
  • 2. Department of Biochemistry and Molecular Biology B and Immunology of the University of Murcia, Spain
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Corresponding Authors
Carbonell Martínez A, Reina Sofia University General Hospital, Allergology Section, Spain
Abstract

Severe food allergies caused by lipid-transporting proteins (LTP) are becoming increasingly prevalent in our environment, predominantly affecting a young population.

CITATION

Carbonell Martínez A, González Pérez A, Escudero Pastor AI, Navarro Garrido C, Miralles López JC, et al. (2023) Evolution of Quality of Life in Patients with Anaphylaxis Due to LTP Syndrome After 3 Years of Specific Immunotherapy and 1 Year after Treatment Completion. JSM Clin Case Rep 11(3): 1221.

INTRODUCTION

The clinical presentation and related symptoms significantly diminish their quality of life. The Food Allergy Quality of Life Questionnaire – Adult form (FAQLQ-AF), developed and validated by Flokstra-de Blok et al. [1], is the first specific questionnaire designed to assess the health-related quality of life (HRQoL) in adult patients allergic to food. This questionnaire has been translated into various languages, including Spanish [2], and cross-validated in the EuropreVall study, a multicenter European food allergy research project with the objective of analyzing the impact of food allergies on the quality of life [3,4].

The LTP syndrome, or Lipid Transfer Protein syndrome, refers to an allergic reaction that can manifest in various ways within the human body. This allergic reaction may initially present as an Oral Allergy Syndrome (OAS) and, in more severe cases, progress to episodes of generalized urticaria affecting the respiratory, digestive, and vascular systems. In extreme situations, this reaction can lead to anaphylaxis, a potentially life-threatening allergic response. Another characteristic of these patients is that they often have rhinitis and/or asthma with pollen allergies.

OBJECTIVES

The primary goal of this study is to investigate the evolution of the quality of life in patients with anaphylaxis due to LTP syndrome after undergoing specific immunotherapy for 3 years and one year after completing the treatment, in comparison to a control group that did not receive immunotherapy.

MATERIAL AND METHODS

Study population: The active group of this study consisted of 21 patients who were over 18 years old and had been diagnosed with anaphylaxis due to LTP syndrome (SLTP). These patients underwent a 3-year treatment regimen involving ALKAbello® peach-specific sublingual immunotherapy (SLIT), which effectively managed their condition. Consequently, they were able to reintroduce a diet that no longer required the exclusion of LTP allergens [5]. On the other hand, the control group included 13 patients with comparable clinical characteristics who made a personal decision not to initiate immunotherapy treatment.

Quality of life test: Patients in the active group underwent a quality of life assessment at the beginning of treatment, at the end of the treatment period, and one year after completing treatment. Patients in the control group underwent the same assessment at the beginning and at the end of the study. The assessment tool used was the S-FAQLQ-AF, which comprises 29 questions grouped into 4 domains for maintaining internal consistency (see Annex 1). Each question is scored from a minimum of 0 to a maximum of 6, resulting in a total score of 174 points (1). The domains or blocks in which the test is structured are: A.- Allergen Avoidance + Dietary Restriction (AADR or Allergen Avoidance and Dietary Restrictions): 11 items: 1, 2, 3, 4, 6, 8, 9, 10, 11, 12, 20. B.- Emotional Impact (EI or Emotional Impact): 7 items: 5, 24, 25, 26, 27, 28, 29. C.- Risk of Accidental Exposure (RAE or Risk of Accidental Exposure): 8 items: 7, 13, 14, 15, 16, 17, 18,21. D. Food Allergy Related Health (FAH or Food Allergy Related Health): 3 items: 19, 22, 23.

The domains or blocks in which the test is structured are: (1)

A.- Allergen Avoidance + Dietary Restriction (AADR or Allergen Avoidance and Dietary Restrictions): 11 items: 1, 2, 3, 4, 6, 8, 9, 10, 11, 12, 20.

B.- Emotional Impact (EI or Emotional Impact): 7 items: 5, 24, 25, 26, 27, 28, 29.

C.- Risk of Accidental Exposure (RAE or Risk of Accidental Exposure): 8 items: 7, 13, 14, 15, 16, 17, 18, 21.

D.- Food Allergy Related Health (FAH or Food Allergy Related Health): 3 items: 19, 22, 23.

Statistical analysis: Statistical analysis was conducted using R (version 4.0.5). Continuous variables were summarized using measures of central tendency and dispersion, including mean, standard deviation, median, quartiles (25% - Q1 and 75% - Q3), minimum, and maximum values. Normality of continuous variables was assessed using the Shapiro-Wilks test. Independent samples were compared using the independent Student’s T-test for normally distributed data or the Mann-Whitney U test for nonnormally distributed data. For dependent samples, the dependent Student’s T-test was used for normally distributed data, and the Wilcoxon signed-rank test was used for non-normally distributed data. A p-value threshold of <0.05 was considered statistically significant. The ggplot2 package [6] was employed for generating the graphs presented in this study  (Tables 1,2) (Graph results 1-5).

Block results A

Graph 1: Block results A

Block results B

Graph 2: Block resultsB

Block results C

Graph 3: Block results C

Block results D

Graph 4 Block results D

Block results Total.

Graph 5: Block results Total.

Table 1: Patient demographics

  Patients with treatment Patients without treatment
Total no-missing, n 21 13
Missing, n  0 0
Gender
Men, n (%) 7 (33.3%) 4 (30.8%)
Women, n (%) 14 (66.7%) 9 (69.2%)
Age
Mean (SD) 40.1 (11.2) 40.3 (12.7)
Median (Q1, Q3) 42.0 (29.0, 49.0) 39.0 (30.0, 46.0)
Min, Max 22.0, 61.0 26.0, 65.0

Table 2: Results of each patient's responsesTable-2: M->Men.    W->Woman.

  Block A Block B Block C Bloc D Total
Age Sex Group A1 A2 A3 B1 B2 B3 C1 C2 C3 D1 D2 D3 T1 T2 T3
42 W Active 45 26 37 24 24 25 38 46 36 15 18 13 122 114 111
29 W Active 65 13 10 39 20 10 42 21 9 18 7 2 164 61 31
25 W Active 51 12 28 39 31 29 32 28 33 18 15 15 140 86 105
41 W Active 27 10 8 34 21 13 28 16 9 16 7 4 105 54 34
22 M Active 62 7 20 35 2 31 44 22 13 18 3 12 159 34 76
38 W Active 48 45 5 33 32 6 47 38 8 18 12 6 146 127 25
28 M Active 58 30 27 40 28 25 32 15 30 14 10 7 144 83 89
50 W Active 66 50 7 42 40 22 48 45 22 18 8 6 174 143 57
50 W Active 46 13 0 0 13 12 38 10 8 17 6 11 132 42 31
42 M Active 51 22 4 41 21 12 46 19 8 18 7 4 156 69 28
61 W Active 58 21 21 36 13 13 39 14 12 18 7 1 151 55 47
26 M Active 41 39 12 21 26 6 33 30 17 14 16 6 109 111 41
47 W Active 61 58 26 40 34 24 37 36 24 18 18 10 156 146 83
54 W Active 64 43 46 42 39 38 48 39 42 18 15 15 172 136 141
37 W Active 51 30 5 35 22 10 42 29 15 18 11 3 146 92 33
48 W Active 52 29 37 35 33 34 28 31 29 16 18 16 131 111 116
26 M Active 60 62 24 41 39 13 39 37 18 17 9 3 157 147 58
31 W Active 46 29 7 40 39 33 40 29 19 17 18 14 143 115 73
44 M Active 59 34 16 36 24 12 35 28 12 14 11 3 144 97 43
49 W Active 45 14 15 39 8 19 36 28 28 18 10 14 136 60 76
52 M Active 62 53 25 42 42 17 45 41 19 17 18 11 167 154 72
26 W Control 65 58 - 36 36 - 42 45 - 15 16 - 158 155 -
27 W Control 45 47 - 32 31 - 29 31 - 16 17 - 122 126 -
36 W Control 61 61 - 41 41 - 47 47 - 18 18 - 167 167 -
30 M Control 53 49 - 35 23 - 39 35 - 15 11 - 142 118 -
65 W Control 52 62 - 38 38 - 40 44 - 13 15 - 143 159 -
46 W Control 20 15 - 20 16 - 12 12 - 9 9 - 61 52 -
39 M Control 62 39 - 42 37 - 44 38 - 18 18 - 166 132 -
42 W Control 10 57 - 7 18 - 8 35 - 3 12 - 28 122 -
27 M Control 17 37 - 18 34 - 19 32 - 3 14 - 57 117 -
33 W Control 66 30 - 36 37 - 43 41 - 18 18 - 163 126 -
43 W Control 36 58 - 36 41 - 27 47 - 12 18 - 111 164 -
62 M Control 66 23 - 42 37 - 48 14 - 18 8 - 174 82 -
48 W Control 65 40 - 42 37 - 43 31 - 18 9 - 168 117  

M->Men.    W->Woman.

 

RESULTS

Table 2 displays the individual results of each patient’s responses to the FAQLQ-AF questionnaire, which is divided into domains (A, B, C, D) and provides a total score (T) at three different time points: at the beginning (time 1), after 3 years of treatment (time 2), and 1 year after discontinuing immunotherapy (time 3).

Tables 3 and 4 present the statistical results,

Table 3. Results of the active group at the beginning of treatment, after 3 years of treatment, and 1 year after completing treatment.

  Mean (SD) Median (Q1, Q3) Min, Max p. value
Block A
Pre-treatment vs. Post treatment
Pre-treatment 53.2 (9.7) 52.0 (46.0, 61.0) 27.0, 66.0 1.40E-06
Post-treatment 30.5 (16.5) 29.0 (14.0, 43.0) 7.0, 62.0
Pre-treatment vs. 1 year post-treatment
Pre-treatment 53.2 (9.7) 52.0 (46.0, 61.0) 27.0, 66.0 9.50E-11
1 year post-treatment 18.1 (12.6) 16.0 (7.0, 26.0) 0.0, 46.0
Post-treatment vs. 1 year post-treatment
Post-treatment 30.5 (16.5) 29.0 (14.0, 43.0) 7.0, 62.0 0.006
1 year post-treatment 18.1 (12.6) 16.0 (7.0, 26.0) 0.0, 46.0
Block B
Pre-treatment vs. Post treatment
Pre-treatment 35.0 (9.7) 39.0 (35.0, 40.0) 0.0 42.0 0.003
Post-treatment 26.2 (11.1) 26.0 (21.0, 34.0) 2.0, 42.0
Pre-treatment vs. 1 year post-treatment
Pre-treatment 35.0 (9.7) 39.0 (35.0, 40.0) 0.0 42.0 0.0002
1 year post-treatment 19.2 (9.7) 17.0 (12.0, 25.0) 6.0, 38.0
Post-treatment vs. 1 year post-treatment
Post-treatment 26.2 (11.1) 26.0 (21.0, 34.0) 2.0, 42.0 0.022
1 year post-treatment 19.2 (9.7) 17.0 (12.0, 25.0) 6.0, 38.0
Block C
Pre-treatment vs. Post treatment
Pre-treatment 38.9 (6.2) 39.0 (35.0, 44.0) 28.0, 48.0 0.00014
Post-treatment 28.7 (10.4) 29.0 (21.0, 37.0) 10.0, 46.0
Pre-treatment vs. 1 year post-treatment
Pre-treatment 38.9 (6.2) 39.0 (35.0, 44.0) 28.0, 48.0 8.20E-07
1 year post-treatment 19.6 (10.2) 18.0 (12.0, 28.0) 8.0, 42.0
Post-treatment vs. 1 year post-treatment
Post-treatment 28.7 (10.4) 29.0 (21.0, 37.0) 10.0, 46.0 7.00E-04
1 year post-treatment 19.6 (10.2) 18.0 (12.0, 28.0) 8.0, 42.0
Block D
Pre-treatment vs. Post treatment
Pre-treatment 16.9 (1.5) 18.0 (16.0, 18.0) 14.0, 18.0 0.001
Post-treatment 11.6 (4.8) 11.0 (7.0, 16.0) 3.0, 18.0
Pre-treatment vs. 1 year post-treatment
Pre-treatment 16.9 (1.5) 18.0 (16.0, 18.0) 14.0, 18.0 9.40E-05
1 year post-treatment 8.4 (5.0) 7.0 (4.0, 13.0) 1.0, 16.0
Post-treatment vs. 1 year post-treatment
Post-treatment 11.6 (4.8) 11.0 (7.0, 16.0) 3.0, 18.0 0.014
1 year post-treatment 8.4 (5.0) 7.0 (4.0, 13.0) 1.0, 16.0
Total score
Pre-treatment vs. Post treatment
Pre-treatment 145.4 (18.6) 146.0 (136.0, 157.0) 105.0, 174.0 5.50E-06
Post-treatment 97.0 (37.5) 97.0 (61.0, 127.0) 34.0, 154.0
Pre-treatment vs. 1 year post-treatment
Pre-treatment 145.4 (18.6) 146.0 (136.0, 157.0) 105.0, 174.0 2.40E-09
1 year post-treatment 65.2 (33.2) 58.0 (34.0, 83.0) 25.0, 141.0
Post-treatment vs. 1 year post-treatment
Post-treatment 97.0 (37.5) 97.0 (61.0, 127.0) 34.0, 154.0 0.002
1 year post-treatment 65.2 (33.2) 58.0 (34.0, 83.0) 25.0, 141.0

Table 4: Comparison of results between the active group and the control group.

Box plots and whiskers (1, 2, 3, 4, 5) (boxplot) have been used to represent the results.

  Mean (SD) Median (Q1, Q3) Min, Max p. value
Block A
Patient with treatment -22.8 (15.4) -21.0 (-31.0, -16.0) -55.0, 2.0 0.021
Patient without treatment -3.2 (24.9) -4.0 (-23.0, 10.0) -43.0, 47.0
BlockB
Patient with treatment -8.7 (11.6) -6.0 (-13.0, -1.0) -33.0, 13.0 0.011
Patient without treatment 0.1 (7.3) 0.0 (-5.0, 1.0) -12.0, 16.0
BlockC
Patient with treatment -10.2 (10.0) -9.0 (-17.0, -3.0) -28.0, 8.0 0.029
Patient without treatment 0.8 (14.9) 0.0 (-4.0, 4.0) -34.0, 27.0
BlockD
Patient with treatment -5.3 (5.4) -6.0 (-10.0, 0.0) -15.0, 3.0 0.009
Patient without treatment 0.5 (6.0) 0.0 (0.0, 2.0) -10.0, 11.0
Total score
Patient with treatment -48.4 (36.2) -47.0 (-76.0, -19.0) -125.0, 2.0 0.008
Patient without treatment -1.8 (49.8) -3.0 (-34.0, 16.0) -92.0, 94.0

comparing the scores of the different domains and the total score of the questionnaire at the three time points within the active group. Additionally, these tables compare the results of the active group with those of the control group. The findings reveal statistically significant differences in all domains and the total score of the questionnaire. Moreover, statistically significant distinctions are evident when comparing the results with the control group.

DISCUSSION

Health-related quality of life (HRQoL) is a term that encompasses various aspects of a person’s well-being, including the impact of disease and its treatment on disability, daily functioning, and overall quality of life. It also reflects how perceived health affects a person’s ability to lead a fulfilling life. Specifically, HRQoL measures the value a person places on their life span, considering impairments, functional states, perceptions, and opportunities influenced by factors such as disease, injury, treatment, and policy [7].

Two primary types of tools are used to assess the impact of different diseases on patients’ quality of life: generic and diseasespecific questionnaires. Generic questionnaires allow researchers to compare various clinical conditions, while disease-specific questionnaires focus on problems associated with a particular disease. Disease-specific questionnaires are better equipped to detect small changes in HRQoL following treatment [8].

According to the 2005 National Allergological Survey of Spain, patients with food allergies, assessed using the SF-12 Generic Questionnaire (physical and mental scales), perceived their quality of life as worse than that of 75% of the Spanish population of similar age and sex [9].

Currently, there is a growing body of research on the quality of life of patients with food allergies [8-10]. Additionally, numerous trials on sublingual immunotherapy (SLIT) in food allergies explore different approaches to managing this clinical condition, including peanut and peach immunotherapy. However, most studies do not specifically examine changes in quality of life after peach or peanut immunotherapy [11,12]. Therefore, it is essential to recognize that lipid-transfer protein syndrome (LTLS) can be severe in many cases and profoundly affect patients’ HRQoL. Thus, it becomes crucial to assess not only the safety and efficacy of SLIT-peach® immunotherapy but also the improvements in HRQoL following long-term SLIT administration and the sustainability of these positive effects after treatment cessation. The significant enhancement in the quality of life observed in our patients following a 3-year course of SLIT-peach® suggests further evidence of the treatment’s beneficial effects.

With this study, our aim was to track the evolution of the questionnaire over the four-year follow-up period of our patients. We have confirmed that the S-FAQLQ-AF (2) is a valuable and indispensable tool for monitoring this patient population.

We believe that this study is groundbreaking in terms of collecting a significant number of patients with LTP syndrome and conducting a four-year follow-up. Based on our findings, we can conclude that patients with anaphylaxis due to LTP syndrome, who underwent treatment with SLIT-peach®, experienced a substantial improvement in their quality of life from the beginning of treatment to its completion (3 years). Furthermore, this enhanced quality of life continued to improve globally up to one year after discontinuing immunotherapy.

CONCLUSIONS

Treatment with SLIT-peach® improves the quality of life of patients, and this improvement is sustained after its completion. This is currently the first 4-year follow-up on anaphylactic diseases in patients with LTP syndrome.

REFERENCES

1. Flokstra-de Blok BM, van der Meulen GN, DunnGalvin A, VliegBoerstra BJ, OudeElberink JN, Duiverman EJ, et al. Development and validation of the Food Allergy Quality of Life Questionnaire - Adult Form. Allergy. 2009; 64: 1209-17.

2. Antolin-Amerigo D, Cerecedo Carballo I, Muriel A, Fernández-Rivas M, Diéguez Pastor M, Flokstra-de Blok B, Dubois A, De la HozCaballer B. Validation of the Spanish Version of the Food Allergy Quality of Life Questionnaire– Adult Form (S-FAQLQ-AF) - J Investig Allergol Clin Immunol. 2015; 25: 270-5.

3. Kummeling I, Mills ENC, Clausen M, Dubakiene R, Pérez CF, FernándezRivas M, et al. The EuroPrevall surveys on the prevalence of food allergies in children and adults: background and study methodology. Allergy. 2009; 64: 1493–7.

4. Keil T, McBride D, Grimshaw K, Niggemann B, Xepapadaki P, Zannikos K, et al. The multinational birth cohort of EuroPrevall: background, aims, and methods. Allergy. 2010; 65: 482-90.

5. Alejandra González, Antonio Carbonell Martínez, Ana Isabel Escudero Pastor, Cristina Navarro Garrido, and Juan Carlos MirallesLópez. Pru p 3 oral immunotherapy efficacy, induced immunological changes and quality of life improvement in patients with LTP syndrome. Clin Transl Allergy. 2020; 10: 2045-7022.

6. Wickham, Hadley. Ggplot2: elegant graphics for data analysis. New York: Springer. 2009;1(6):1-7.

7. Haraldstad K, Wahl A, Andenæs R, Andersen JR, Andersen MH, Beisland E, Borge CR, Engebretsen E, Eisemann M, Halvorsrud L, Hanssen TA, Haugstvedt A, Haugland T, Johansen VA, Larsen MH, Løvereide L, Løyland B, Kvarme LG, Moons P, Norekvål TM, Ribu L, Rohde GE, Urstad KH, Helseth S; LIVSFORSK network. A systematic review of quality of life research in medicine and health sciences. Qual Life Res. 2019;28(10):2641-2650.

8. Dunn Galvin A, Hourihane JO. Health-related quality of life in food allergy: Impact, correlates, and predictors. BundesgesundheitsblattGesundheitsforschungGesundheitsschutz. 2016; 59: 841-8.

9. Fernández Rivas M. Food allergy in Allergológica 2005. J InvestigAllergolClinImmunol. 2009; 19: 37-44.

10. Pajno GB, Fernandez-Rivas M, Arasi S, Roberts G, Akdis CA, AlvaroLozano M, Beyer K, Bindslev-Jensen C, Burks W, Ebisawa M, Eigenmann P, Knol E, Nadeau KC, Poulsen LK, van Ree R, Santos AF, du Toit G, Dhami S, Nurmatov U, Boloh Y, Makela M, O’Mahony L, Papadopoulos N, Sackesen C, Agache I, Angier E, Halken S, Jutel M, Lau S, Pfaar O, Ryan D, Sturm G, Varga EM, van Wijk RG, Sheikh A, Muraro A; EAACI Allergen Immunotherapy Guidelines Group. EAACI Guidelines on allergen immunotherapy: IgE-mediated food allergy. Allergy. 2018; 73(4):799-815.

11. Palomares F, Gomez F, Bogas G, Campo P, Perkins JR, Diaz Perales A, Rodriguez MJ, Prieto A, Barber D, Torres MJ, Mayorga C. Immunological Changes Induced in Peach Allergy Patients with Systemic Reactions by Pru p 3 Sublingual Immunotherapy. MolNutr Food Res. 2018 ;62(3):10-1002.

12. Joo Chan C, Richardo T, Lim RLH. Current Trend in Immunotherapy for Peanut Allergy. Int Rev Immunol. 2018;37(6):279-290.

Carbonell Martínez A, González Pérez A, Escudero Pastor AI, Navarro Garrido C, Miralles López JC, et al. (2023) Evolution of Quality of Life in Patients with Anaphylaxis Due to LTP Syndrome After 3 Years of Specific Immunotherapy and 1 Year after Treatment Completion. JSM Clin Case Rep 11(3): 1221.

Received : 02 Sep 2023
Accepted : 30 Sep 2023
Published : 30 Sep 2023
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ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
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