Chronic infection by hepatitis B virus (HBV) and hepatitis D virus (HDV) continues to pose a major public health challenge in Spain due to its high morbidity and mortality and the risk of progression to cirrhosis and hepatocellular carcinoma. Although effective tools exist for the control of hepatitis B and recent therapeutic advances have been made for hepatitis D, significant inequalities persist in early diagnosis, access to treatment, and appropriate patient follow‑up. This consensus document has been jointly developed by the Spanish Association for the Study of the Liver (AEEH), the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC)—through its Viral Hepatitis Study Group (GEHEP)—the Spanish Society of Digestive Pathology (SEPD), the Spanish Society of Family and Community Medicine (semFYC), the Spanish Society of Hospital Pharmacy (SEFH), the Alliance for the Elimination of Viral Hepatitis in Spain (AEHVE), and the Spanish Society of Paediatric Gastroenterology, Hepatology and Nutrition (SEGHNP). The objective is to provide updated and consensus‑based recommendations on the diagnosis, management, and treatment of chronic HBV and HDV infection, from a multidisciplinary perspective and adapted to real‑world clinical practice. The document addresses screening and diagnostic strategies, criteria for assessing liver fibrosis, indications for antiviral treatment, specific management of hepatitis D, and the role of coordination between primary care and hospital care. Likewise, it emphasizes the need to implement strategies to advance toward the goals of viral hepatitis elimination.
INTRODUCTION:Aerosol therapy during invasive mechanical ventilation is a common practice in intensive care units, however, its effectiveness is highly dependent on technical factors. Variability in device positioning and nursing technique produces substantial differences between the nominal dose and the fraction of drug that reaches the lungs, underscoring the need for standardized placement to enhance both safety and therapeutic efficiency. OBJECTIVE:To examine recent scientific evidence to determine the optimal positioning of aerosol delivery devices within the ventilator circuit, thereby guiding nursing practice toward standardized, evidence-informed procedures. METHODOLOGY:Systematized review (2018-2025) conducted in PubMed, BVSalud, and complementary academic search engines. MeSH, DeCS, and free-text terms related to aerosol therapy and mechanical ventilation were used. The PIO framework was applied following PRISMA guidelines and GRADE assessment. From 165 initial records, eight original studies were included. RESULTS:Vibrating mesh nebulizers demonstrated greater efficiency when positioned on the inspiratory limb, either near the Y-piece (10-15 cm) or at the humidifier inlet. Jet nebulizers showed optimal placement varying according to the device type (continuous, breath-actuated, or synchronized), although their overall performance was inferior to that of vibrating mesh nebulizers. Metered-dose inhalers were most effective when positioned on the inspiratory limb before the Y-piece, particularly when used with a spacer. CONCLUSIONS:The available evidence suggests that device positioning influences the efficiency of aerosol therapy during invasive mechanical ventilation. Vibrating mesh nebulizers and properly positioned inhalers may improve pulmonary drug delivery; however, the overall certainty of the evidence remains low.
OBJECTIVE:To assess the impact of the Healthcare Triad Model (HTM) on Primary Care accessibility by analyzing changes in Average Response Time (ART). DESIGN:Multicenter, retrospective, quasi-experimental before-and-after study. SETTING:Three primary care centers within the Jerez, Costa Noroeste and Sierra de Cádiz Health Management Area (Andalusia, Spain). PARTICIPANTS:Thirty physicians with continuous clinical activity throughout the study period. Data from the two months before and two months after implementation were analyzed, excluding the rollout phase and summer months. INTERVENTIONS:Implementation of the Healthcare Triad Model, which integrates family physicians, nurses, and citizen care units to reorganize care demand management. MAIN OUTCOME MEASURE:Average Response Time (ART), defined as the number of days until a scheduled medical appointment. RESULTS:Median ART decreased from 8.93 to 4.61 days, representing a median relative reduction of 39.5% (interquartile range [IQR]: 31.1-55.3; p <0.0001). Improvement was observed in 28 of 30 physicians. Multivariable analysis showed no significant associations between ART reduction and individual professional or workload characteristics. CONCLUSIONS:The Healthcare Triad Model significantly improves Primary Care accessibility through organizational redesign, independently of individual professional factors.
Objectives To evaluate the efficacy and safety of immune checkpoint inhibitors in the first-line treatment of microsatellite instability or mismatch repair-deficient metastatic colorectal cancer through a systematic review and adjusted indirect comparison, determining whether they are equivalent therapeutic alternatives. Methods A systematic literature search was conducted in PubMed and Embase following PRISMA 2020 recommendations. Phase III randomized controlled trials evaluating immune checkpoint inhibitors in microsatellite instability or mismatch repair-deficient metastatic colorectal cancer were eligible. Efficacy was assessed using Bucher's adjusted indirect comparison method, with progression-free survival as the primary endpoint. Therapeutic equivalence was evaluated according to the Equivalent Therapeutic Alternatives framework, applying a non-inferiority margin (Δ) of 0.65. Safety outcomes included overall and treatment-related adverse events, immune-related adverse events, discontinuations due to adverse events and grade 5 events. Results NI demonstrated a higher probability of superior efficacy over pembrolizumab, with an adjusted Hazard Ratio of 0.53 (95%CI 0.34 to 0.84) for progression-free survival, exceeding the equivalence margin. Thus, pembrolizumab and nivolumab+ipilimumab cannot be considered Equivalent Therapeutic Alternatives regarding efficacy. In terms of safety, nivolumab+ipilimumab was associated with fewer treatment-related grade ≥ 3 adverse events but higher rates of treatment discontinuation and immune-related adverse events compared to pembrolizumab. Discussion Nivolumab+ipilimumab appears to offer greater efficacy than pembrolizumab in first-line treatment of microsatellite instability or mismatch repair-deficient metastatic colorectal cancer, but with a distinct safety profile. Based on current interim data, these agents should not be regarded as equivalent therapeutic alternatives. Further data, including final efficacy analyses and quality-of-life assessments, are warranted to guide optimal treatment selection.
