Think Forward.

L’hépatite auto-immune : en l’absence de traitement, la maladie évolue vers la destruction du foie 3336

Dr Moussayer khadija, 2 y.

- Health -

3.6 min read.

AVERTISSEMENT : article dont certains éléments sont plutôt réservés à un public averti L'hépatite auto-immune est une maladie dans laquelle le propre système immunitaire de l'organisme attaque le foie. La maladie est chronique et susceptible de durer des années. Si elle n'est pas traitée, elle peut causer une cirrhose et une insuffisance hépatique. Elle se caractérise par une cytolyse hépatique ('augmentation d'enzymes qui montrent la destruction d'hépatocytes), une hypergammaglobulinémie polyclonale (résultant d'une surexpression d'immunoglobulines due à une activation lymphocytaire B), la présence d’auto -anticorps sériques et par une infiltration lymphocytaire périportale. En l’absence de traitement, la maladie évolue vers la destruction du foie. Chez certains patients on peut observer des poussées qui peuvent être responsables d’une insuffisance hépatique aigüe. Il existe deux types d’hépatites auto-immunes, le type 1 diagnostiqué surtout chez l’adulte et caractérisé par la présence d’anticorps anti-muscle lisse, et le type 2 caractérisé par la présence d’anticorps anti-LKM1, surtout observé chez l’enfant. EPIDEMIOLOGIE L’HAI est une maladie rare : son incidence est estimée entre 2 et 4 /100 000 personnes par an. Elle représente moins de 6 % des hépatites chroniques en France. La prévalence varie selon un gradient nord-sud, il existe une fréquence plus élevée en Europe du Nord en relation à l’association avec l’haplotype HLA A1-B8-DR3. Des gènes de susceptibilité pour les maladies auto-immunes sont présents chez les patients et dans leur famille. A côté de l’atteinte hépatique, chez ces patients, il est fréquent d’observer d’autres maladies auto-immunes extra-hépatiques. La maladie peut débuter à tout âge, mais elle est particulièrement fréquente entre 10 et 30 ans et 40 à 50 ans. Elle touche à la fois les hommes et les femmes, mais il existe une nette prédominance féminine selon un ratio de 4 pour 1. En effet, les HAI touchent essentiellement la femme (70% des cas) et 50% des patientes affectées ont moins de 40 ans. Il existe également un pic d’incidence en période pré-pubertaire, à 10 ans pour le type 1 et à 6 ans et demi pour le type 2. La maladie est plus fréquente en phase pré-pubertaire et chez les filles. LES SYMPTOMES La présentation clinique est variable, près d’un tiers des patients atteints d’HAI 2T étant asymptomatiques, ce qui peut être à l’origine d’une reconnaissance tardive de la maladie, au stade de cirrhose dans 25% des cas. Ailleurs, on peut observer un ensemble de symptômes non spécifiques, tels que l'asthénie (85% des cas), un ictère (80%), une hépatomégalie (80%) ou des hépatalgies (50%). Dans environ 30% des cas, le mode de présentation est aigu et peut mimer un tableau d’hépatite virale. Plus rarement et en particulier dans les formes d’HAI-2 de l’enfant, la maladie peut se déclarer sous une forme sub-fulminante ou fulminante. Dans la moitié des cas, des manifestations dysimmunitaires extra-hépatiques telles que des arthralgies, une dysthyroïdie ou un diabète insulinodépendant peuvent être associés. La préobéit à 3 situations : · Des anomalies du bilan hépatique avec peu ou pas de symptômes. · Un tableau d’« hépatite aiguë » comprenant un ictère, des hépatalgies et des troubles digestifs. Ce mode de révélation concerne plus de la moitié des cas et ce début aigu pouvant aller jusqu'à l'hépatite fulminante. · Un atteinte hépatique chronique responsable d’une cirrhose installée à bas bruit : angiomes stellaires, érythrose palmaire, hippocratisme digital ou présence de signes d'hypertension portale (splénomégalie, ascite, hémorragie digestive...). DIAGNOSTIC La maladie doit être évoquée devant toute élévation des transaminases car la méconnaître peut comporter un risque d’évolution rapide vers la cirrhose, alors qu’un diagnostic précoce, compte tenu de l’efficacité des corticostéroïdes et des immunosuppresseurs, entraîne la guérison. L’enjeu du diagnostic est de différencier une origine virale d’une cause auto-immune de l’hépatite : le traitement par interféron d’une HAI peut être fatal ; il en est de même d’un traitement immunosuppresseur d’une hépatite virale. Le diagnostic repose sur les données de la biologie hépatique et la recherche des marqueurs. La biopsie du foie reste indispensable pour le diagnostic et pour la prise en charger. Aucun de ces éléments n’est spécifique et le diagnostic reste celui d’exclusion. Il convient d’éliminer d’autres diagnostics : hépatites virales, hépatites médicamenteuses, la maladie de Wilson, l’hémochromatose, le déficit en alpha1 antitrypsine. Dans les formes cholestatiques, il faut en particulier réaliser une cholangio-IRM (en l’absence d’anticorps antimitochondries). Chez environ 10 à 20% des malades, l’HAI est associée à une cholangite biliaire primitive réalisant un syndrome de chevauchement. TRAITEMENTS Il est fondé sur les corticoïdes et l'azathioprine. En seconde ligne, on peut utiliser le tacrolimus, le mycophénolate mofétil (MMF) ou encore des anticorps anti-CD20. Le MMF paraît très efficace en terme de réponses biologique et histologique chez des patients en rechute après l’association corticoïdes-azathioprine. La durée de traitement est de plusieurs années et 2 ans de biologie normale sont indispensables avant une décroissance ou un arrêt thérapeutique. L’acide ursodesoxycholique associée à la corticothérapie, apporte un bénéfice au moins biologique à des doses de 750 mg/j. Ce traitement est conseillé dans les formes frontière La transplantation hépatique est indiquée en cas d’hépatite (sub) fulminante résistant à un traitement à fortes doses par corticoïdes ou en cas de cirrhose accompagnée de complications sévères. L’hépatite auto-immune représente environ 5% des indications de transplantation pour cirrhose. Le taux de survie après transplantation est de 90% à cinq ans et de 75% à dix ans. La maladie peut récidiver jusque dans 40% des cas ; cette récidive, qui peut se manifester sous différentes formes (parfois sévères), serait favorisée par une immunosuppression insuffisante ou par un greffon présentant l’haplotype HLA DR3. Dr MOUSSAYER KHADIJA الدكتورة خديجة موسيار Spécialiste en médecine interne et en Gériatrie. Présidente de l’association marocaine des maladies auto-immunes et systémiques OVERVIEW Autoimmune hepatitis is liver inflammation that occurs when your body's immune system turns against liver cells. The exact cause of autoimmune hepatitis is unclear, but genetic and enviromental factors appear to interact over time in triggering the disease. Untreated autoimmune hepatitis can lead to scarring of the liver (cirrhosis) and eventually to liver failure. When diagnosed and treated early, however, autoimmune hepatitis often can be controlled with drugs that suppress the immune system. A liver transplant may be an option when autoimmune hepatitis doesn't respond to drug treatments or in cases of advanced liver disease.

Dr Moussayer khadija

Dr MOUSSAYER KHADIJA الدكتورة خديجة موسيار Spécialiste en médecine interne et en Gériatrie en libéral à Casablanca. Présidente de l’Alliance Maladies Rares Maroc (AMRM) et de l’association marocaine des maladies auto-immunes et systémiques (AMMAIS), Vice-présidente du Groupe de l’Auto-Immunité Marocain (GEAIM)

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Football: When Passion Kills the Game in Impunity and Tolerance.. 418

Aziz Daouda, 2 d.

- Society - Sports -

2.7 min read.

Football (Soccer for Americans) is first and foremost a matter of emotions. By its very essence, it is an open-air theater where human passions play out in their rawest, most primal form. It generates joy, anger, pride, humiliation, and a sense of belonging. From the stands of Camp Nou to those of the Diego Armando Maradona Stadium, through the fervor of the Mohamed V sport Complex in Casablanca, the vibrant enclosures of Stade Léopold Sédar Senghor in Dakar, or even the Parc des Princes in Paris, the Vélodrome In Marseille, and the Bernabeu In Madrid, football transcends the mere framework of the game to become a total social phenomenon. But this emotional intensity, which makes football's beauty, also constitutes its danger. For without rigorous regulation, it quickly tips into excess, then into violence. Today, it must be acknowledged that the rules exist, but they are too often circumvented, stripped of their substance, or applied with disconcerting leniency. On the pitches as in the stands, excesses are multiplying: insults toward referees, provocations between players, systematic challenges, physical violence, projectile throwing, pitch invasions, xenophobic remarks, racist offenses. What was once the exception is tending to become a tolerated norm. Astonishingly, we are starting to get used to it. Recent examples are telling. In Spain, in stadiums renowned for their football culture, racist chants continue to be belted out without shame, targeting players like Vinícius Júnior. Most recently, it was the Muslim community that was insulted. And yet, Spain's current football prodigy is Muslim. An overheated crowd that has doubtless forgotten it wasn't so long ago that it was Muslim itself. Among those chanting these remarks, and without a doubt, some still carry the genes of that recent past... In Dakar, just a few days ago, clashes escalated, turning a sports celebration into a scene of chaos. In Italy, incidents involving supporters who invaded the pitch, during a friendly match, no less, endangered players and officials, recalling the dark hours of European hooliganism in the 1980s. These episodes are not isolated; they reflect a worrying normalization of violence in and around stadiums. Even at the highest level of African football, behavioral excesses are becoming problematic. The 2025 Africa Cup of Nations final left a bitter taste. What should have been a moment of celebration for continental football was marred by behaviors contrary to sporting ethics. Pressures on refereeing, excessive challenges, and game interruptions have become commonplace. When a coach manipulates a match's rhythm to influence a refereeing decision, it is no longer strategy but a challenge to the very foundations of the sport. Despite international outrage, the sanctions imposed on teams, clubs, or players involved remain often symbolic, insufficient to eradicate these behaviors. A very surprising phenomenon: rarely have clubs or federations clearly distanced themselves from such crowds. They accommodate them, and when they condemn them, it is half-heartedly, in a muffled, timid tone with no effect. The problem is twofold. On one hand, disciplinary regulations exist but lack firmness. On the other, their application suffers from a lack of consistency and political courage. Bodies like FIFA, continental confederations, and national federations hesitate to impose truly dissuasive sanctions such as point deductions, prolonged closed-door matches, competition exclusions, or even administrative relegations. Yet without fear of sanction, the rule loses all effectiveness. It suffices to compare with other sports to measure the gap. In rugby, for example, respect for the referee is a cardinal value. The slightest challenge is immediately sanctioned. In athletics, a false start leads to immediate disqualification, no discussion. Football, meanwhile, still tolerates too many behaviors that should be unacceptable. This permissiveness has a cost. It undermines football's image, discourages some families from attending stadiums, and endangers the safety of the game's actors. More gravely, it paves the way for future tragedies. History has already taught us, through catastrophes like the Heysel Stadium disaster, that violence in stadiums can have tragic consequences. It is therefore urgent to react. Regulating football does not mean killing its soul, but rather preserving it. It is not about extinguishing passions, but channeling them. This requires strong measures, exemplary sanctions against offending clubs and players, accountability for national federations, increased use of technology to identify troublemakers, and above all, a clear political will from national and international governing bodies. Football cannot continue to be this "market of emotion" left to its own devices. For by tolerating the intolerable, it risks losing what makes its greatness and its ability to unite rather than divide. If FIFA does not decide to act firmly, the danger is real: that of seeing football sink into a spiral where violence triumphs over the game, and where, one day, tragedies exceed the mere framework of sport. The long-awaited decision of the Court of Arbitration for Sport (CAS) in the 2025 AFCON final case should confirm rigor and integrity in the application of rules, at least at this level, thereby strengthening the credibility of the pan-African competition and football in general.

April 2026 or the Certain Confirmation of the Moroccan Victory... 618

Aziz Daouda, 3 d.

- World Politics - History -

3 min read.

We are entering a decisive month of April. The international dynamic is shifting even further in Morocco's favor on the Sahara issue. April once again promises to be a pivotal moment in the international handling of the Moroccan Sahara question. This structuring diplomatic ritual corresponds to the presentation of the annual report by the UN Secretary-General's Personal Envoy to the Security Council. But this year, the context is profoundly different. The lines have shifted, balances have been redrawn, and a new dynamic is taking hold, clearly favorable to Morocco, a logical follow-up to the adoption of Resolution 2797, with strong structuring potential. The adoption of this resolution marks an essential milestone. It goes beyond simply renewing the existing framework. It consolidates a political direction initiated over several years, by enshrining the preeminence of a realistic, pragmatic, and sustainable political solution, centered exclusively on the Moroccan autonomy initiative. This resolution fits into a strategic continuity that progressively marginalizes unrealistic options, those that long relied on outdated or inapplicable references in the current geopolitical context. It also increases pressure on the parties to engage in a credible political process under the exclusive auspices of the United Nations, but in reality under strong American pressure. The United States has directly engaged in favor of the Kingdom, with the return of roundtables in Madrid and then Washington as key pivots. These meetings have confirmed a diplomatic reality that is now hard to contest. The format of the gatherings, including Morocco, Mauritania, the Polisario Front, and Algeria despite itself, is the only relevant framework for progress. It implicitly enshrines Algeria's central role, long eager to present itself as a mere observer. Its active participation, even forced, places it at the heart of the dispute, profoundly altering the reading of the conflict and redistributing political responsibilities. Madrid and Washington are not insignificant venues. They reflect the growing involvement of Western powers in seeking a resolution, with increasing convergence around the Moroccan proposal. One of the expected developments this month concerns the future of MINURSO. The time has come to redefine the mission. From its inception, it has never fulfilled the role for which it was established. A major evolution is likely emerging in support of implementing autonomy in the southern provinces within the framework of the Kingdom's sovereignty. Long confined to monitoring the ceasefire, the mission will see its name change and its mandate evolve to adapt to on-the-ground realities and the demands of a renewed political process. Such a change would be highly significant. It would mark the end of UN inertia and reflect the international community's will to move from managing the status quo to an active and definitive resolution logic. Much to the dismay of those who, for 50 years, have done everything to perpetuate the conflict through their proxy; the latter is increasingly suffering from the shifting landscape. Washington has toughened its tone and put the Polisario in its sights. Algeria is evidently feeling the effects. The introduction in the US Congress of a proposal to designate the Polisario as a terrorist organization represents a potentially major turning point. If successful, such a designation would have considerable political, financial, and diplomatic consequences. It would further isolate the movement, weaken its supporters, and reshape the balance of power. Above all, it would reinforce the security reading of the dossier, in a Sahel-Saharan context marked by rising transnational threats. This adds to a Security Council increasingly aligned with the Moroccan position. The Council's current composition clearly leans in favor of Moroccan positions. Several influential members explicitly or implicitly support the autonomy initiative, seen as the most serious and credible basis for settlement. This shift is no accident. It results from active, coherent, and consistent Moroccan diplomacy, which has successfully embedded the Sahara issue within logics of regional stability, counter-terrorism, and economic development. Algeria, for its part, faces its contradictions. In this context, the Algerian regime appears increasingly beleaguered. Its positioning, long structured around ideological rhetoric and systematic opposition to Morocco, now seems out of step with international system evolutions. Algiers' relative diplomatic isolation, including in its Sahelian environment, contrasts with its regional ambitions. Internally, economic and social challenges exacerbate tensions in a country with considerable resources but unevenly distributed benefits. Algerian populations suffer from much injustice and lack the essentials. The Sahara issue, instrumentalized for decades as a lever for foreign policy and internal cohesion, thus reveals the limits of a politically exhausted model. The trend thus confirms a historic turning point depriving the Algerian regime of its artificial political rent. All elements converge toward one conclusion: April 2026 could mark a decisive step in the evolution of the Moroccan Sahara dossier. Without prejudging an immediate outcome, current dynamics are progressively narrowing the space for blocking positions. More than ever, resolving this conflict seems to hinge on recognizing geopolitical realities and adhering to a pragmatic political solution. In this perspective, Morocco appears in a position of strength, bolstered by growing legitimacy and increasingly assertive international support. The question remains whether other actors, particularly Algeria, will adapt to this new reality or choose to oppose it at the risk of greater isolation in a world where balances of power evolve rapidly. There will undoubtedly be a before and after April 2026, and above all, the consolidation of a Moroccan position oriented toward further development of the southern provinces. The Security Council's output is awaited in this direction.