Slow progression of hepatitis C virus (HCV) infection can compromise liver function and lead to cirrhosis and hepatocellular carcinoma. The action of the virus is silent and can be maintained for years, but it is not inexorable: treatment with direct-acting antivirals (oral drugs and almost no side effects) cures the infection in practically all cases..

Spain is the country in the world that has treated the most patients with hepatitis C per million population: at least 165,000, say the Alliance for the Elimination of Viral Hepatitis in Spain (Aehve).. However, they also estimate that almost 30% of people with active infection are unaware of their situation. Most are between 40 and 69 years old..

Work is being done everywhere to detect these infected people as soon as possible and thus treat them, using different approaches. But the strategy that is being carried out in Galicia has some innovative ingredients that make it stand out from other formulas..

In addition, it invites us to think that the region will be the first in Europe to reach the goal of eliminating hepatitis C proposed by the World Health Organization (WHO).. An objective that pursues, among other indicators, to reduce, before 2030, new infections by 90% and deaths by more than 65% compared to 2015, when curative treatments appeared.

The Plan launched five months ago by the Galician Public Health Directorate contemplates opportunistic age screening, understood as the automatic offer of the hepatitis C test to any person of a certain age who for any reason goes to the health system and has to have a blood test.

The offer appears automatically, something possible thanks to the integration of the electronic medical record in the Galician community, and this avoids an unnecessary overload to the professional who cares for the patient, in addition to ensuring inclusion in the screening.

What does this screening or 'pooling' consist of?

In this first year it is offered to those between 50 and 59 years old; in the next two, people from 60 to 69 will be added first, and already in 2025, those from 40 to 49, until the target population group is completed. This screening is carried out in a pioneering way with a group of samples analyzed by PCR, a technique also known as pooling.

The pooling technique has already been used in the covid-19 pandemic, due to the shortage of reagents to perform RT-PCR tests. A study carried out by microbiologists Federico García (Granada University Hospital) and Antonio Aguilera (Santiago University Complex) and published in The Lancet Gastroenterology and Hepatology, endorsed its use in population screening for hepatitis C.

Juan Turnes, head of the Digestive System Service of the University Hospital Complex of Pontevedra (CHOP) and one of the specialists who has participated in the preparation of the Galician Plan, explains to this medium how the technique is applied.

“As far as we know, it is the only plan worldwide that is performing screening through pooling. We pool blood samples from 100 people to perform a single PCR, which costs around 30-40 euros. The estimated prevalence of the virus in people between the ages of 50 and 59 -those with the highest risk of hepatitis C in Spain- is 0.4-0.5%, that is, between four and five out of every 1,000 people.. With pools of 100 samples, it is very likely that many will be negative”.

With pooling, two things are sought, summarizes the specialist: on the one hand, to make quick and accurate diagnoses, something that the detection of antibodies does not offer, and that with RT-PCR is achieved in 24-48 hours.

Secondly, the grouping of samples “reduces costs in the Galician scenario of just over 50%”, a key element in the strategy to eliminate this viral hepatitis. “Although when talking about diseases, one usually thinks first of the cost of treatments, here the cost of detection and diagnosis has been given more weight. It must be taken into account that current drugs cure 100% of patients in practice: the few who do not respond to a first treatment do so to the rescue one”.

Carmen Durán Parrondo, general director of Public Health of the Galician Ministry of Health, points out that “in the first five months of development of the screening, 31,000 tests have been carried out and 38 cases of hepatitis C have been detected, that is, the monitoring of the program by professionals is high and its performance is consistent with the bibliography”.

And he adds that “from the General Directorate of Public Health we are convinced that this line of action together with the work with risk groups and primary prevention will contribute significantly to eliminating hepatitis C in Galicia, which is why progress is being made in other initiatives that can help speed up the phase-out process”.

Economic advantages of the technique

Juan Turnes is optimistic about the success of the strategy. “I am convinced that by 2024 we will have reached the WHO elimination criteria, although that does not mean that the plan will stop at that time, as there will still be people who are unaware that they have the infection”.

For the Aehve, the strategy of the Galician community marks “the path for all of Spain” and they ask the rest of the autonomies to follow their example by implementing opportunistic age screening through pooling.

“Doubts about opportunistic screening by age must be abandoned, since pooling samples means lower costs that make diagnostic efforts much more efficient and viable,” says the Aehve coordinator and head of the Hepatology Section of the University Hospital. La Paz, from Madrid, Javier García-Samaniego, who considers that the Galician experience provides sufficient evidence for a more ambitious review of the current diagnostic strategy of the Ministry of Health, currently limited to screening for risk factors.

For his part, Juan Turnes highlighted the support of the regional health authorities. He considers it “essential so that hepatologists can meet our objective of eliminating hepatitis C”, and stresses that the support comes from years ago, with different pilot projects that have served as proof of concept..

The specialist indicates that the plan in Galicia is completed with micro-elimination actions, aimed at small groups, such as people in prisons or among intravenous drug users.

And, within the macro-elimination strategy -aimed at large population groups- it also includes the search using artificial intelligence for people who at some point years ago were diagnosed with hepatitis C, but were never linked to treatment.

Artificial intelligence, a key resource

“We use artificial intelligence software from the Ministry of Health that was successful in a pilot test carried out in Pontevedra, during the pandemic. The tool was used to review thousands of histories in a semi-automatic way and thus we recovered (which implies the start of treatment) 60% of those people with the infection, a percentage higher than those reported in other countries of the European Union”.

One of the problems with screening is that not all people in whom the infection is detected are willing to start treatment.. If they are in the asymptomatic phase, they are fine; sometimes they belong to vulnerable groups that are not used to having contact with the health system.

However, explains Juan Turnes, “when the person has developed cirrhosis, it will not disappear. Although his vital prognosis will improve when treated, since the disease will not continue to progress, he will have a series of increased risks for life, for example, that of developing liver cancer.”.

There is still no data on what moment of the infection the 38 individuals in this plan were detected, but in the artificial intelligence search pilot test they found that of the 60% of people recovered, “one in four already had liver cirrhosis, and no symptoms”.

For this reason, Turnes considers it important to convey to the population that HCV infection has free treatment, lasting two to three months and is capable of curing practically one hundred percent of people with almost no side effects, to say none..

“Today a diagnosis of hepatitis C is not bad news, because detection, especially if it is early, will always be accompanied by a cure for the infection. In how many diseases can we say the same?”

Diagnosis in the localized phase continues to be one of the great challenges in the management of lung cancer, the tumor with the highest mortality.. “Diagnosing before, we could apply all the treatments at our disposal that seek a curative intention. We can currently do this in less than 25% of cases,” says Juan Carlos Trujillo, clinical chief of Thoracic Surgery at the Hospital de la Santa Creu i Sant Pau, in Barcelona, and coordinator of the Cassandra project for screening for lung cancer.

The remaining 75% of cases are diagnosed in an advanced or locally advanced stage.. As he points out, “the techniques have evolved a lot, but the treatment does not offer a guarantee of curing the disease, although it does increase survival. The highest mortality is probably linked to late diagnosis”. The reasons for this diagnostic delay are that this type of tumor does not cause symptoms until advanced stages of the disease.

According to his criteria, the ideal screening program is the one that diagnoses the largest number of patients in an initial phase of the disease with the lowest rate of false positives and negatives, “with sensitivity and specificity on par.”

About 85% of cases are linked to tobacco use. For this reason, Trujillo stresses that primary prevention, in addition to early diagnosis, must focus “on smoking cessation campaigns that work. We have two anti-tobacco laws that have not been successful.”. Regarding the 15% of diagnosed patients who do not smoke, he considers that they are “a therapeutic and diagnostic challenge: they have lung cancers with biomolecular characteristics that are different from other tumors.”

Both Trujillo and Fernando López-Ríos, head of the Molecular Pathology Section at the 12 de Octubre University Hospital in Madrid, have participated in the Visionaries project in lung cancer, an initiative whose objective is to act urgently for prevention and diagnosis early lung cancer. The report has had the collaboration of more than a dozen personalities from different fields whose recommendations are aimed at better understanding and detection of the disease.

For López-Ríos, biomarkers play a crucial role in this field. “We have to ensure that all patients with lung cancer who are operated on in earlier stages have an exhaustive notation of potentially predictive biomarkers,” he explains.

What is the role of mass sequencing?

In the opinion of López-Ríos, “the only way to achieve this is by doing massive sequencing, something that is not complicated, but that implies a paradigm shift: these tests should be done in all patients as they are diagnosed and in a reflex way, something that we currently do only in the most advanced patients. At this time, there is already scientific evidence that some of these biomarkers must be studied, such as EFGR -with PCR techniques or massive sequencing- and PDL1, by immunohistochemistry.. In the near future, it will be necessary to study more and more.”

“It can be argued whether these tests should be done even though the patient does not need this information. But it must be taken into account that a significant percentage of patients in the initial stages -which can reach 30% according to the series- ends up recurring.. That is why it is better to have that information, since it allows you to plan future options,” he says.

Another aspect that he considers relevant is the prognostic argument, “since we know that many of these alterations confer a worse prognosis. In addition, the more massive sequencing is done, the cheaper and faster it will be.. It may be paradoxical, but in some way, patients in early stages could be helping patients in advanced stages to get their results faster and more efficiently,” he summarizes.

How is the British model?

Regarding successful models in this field, López-Ríos highlights the cases of the United Kingdom, France, some regions of Germany and some large American centers. “In Spain, in some regions, it is also beginning to be a reality,” he recalls.

Trujillo agrees with the British model of early diagnosis as “the main mirror in which to look at ourselves”. Remember that the aforementioned country has started a campaign with a pilot study in which almost 80 million euros have been invested. “They are obtaining very important rates of adherence in the population at risk, with improved results in cancer survival.” It also considers the cases of Poland, Belgium, the Czech Republic and the Netherlands relevant.

“Each country must look for its screening program, because smoking rates are not homogeneous. And we must add the risk factors present in each autonomous community, such as radon or contact with asbestos. That is what we are trying to do with the Cassandra program, which we will present in April with 35 centers involved”, he concludes.

It is already a reality: the northern hemisphere suffers more and more heat waves. As the years go by, the temperatures typical of the tropics are closer to those of temperate countries.. It is enough a small return to the images and testimonies that the

The director of NASA, Bill Nelson, is visiting Argentina and there, in a brief meeting with the press, he explained that “in view of all the suspicions that exist with the subject of extraterrestrials”, he has decided to “appoint a committee made up of by distinguished scientists” who will publish a report on this issue next month.

A subcommittee of the United States Congress asked the government last Wednesday to report the data it has on unidentified flying objects after hearing the statement of former members of the army who claim to have seen them and who also say that the authorities keep evidence of them.

The three retired soldiers assured that the US authorities have detected over the country's airspace for decades as a threat to national security, regardless of its origin.

They all testified before a US House of Representatives subcommittee tasked with investigating so-called “unidentified anomalous phenomena,” or UFOs.

Given the abundance of witnesses, in many cases both military and civilian pilots, the members of the subcommittee demanded that the US government establish a “transparent and secure” system so that these incidents can be reported to the authorities without damaging the reputation of the witnesses.

The most spectacular testimony was that of David Grusch, a US Air Force intelligence officer, who stated that the US authorities are in possession of both spacecraft of extraterrestrial origin and the remains of their occupants.

Grusch also noted that the United States has a program to study alleged alien technology and try to reproduce it through so-called reverse engineering.

The former intelligence officer, who on numerous occasions refused to provide specific details when asked by congressmen because it was classified information, also stated that some of the people who work with this extraterrestrial technology have been injured in accidents while trying to manipulate the captured equipment. .

Lt. Ryan Graves, a former US Navy F-18 fighter pilot, noted in his opening statement that “if UFOs are foreign drones, they are an urgent national security issue.”

Graves added that if UFOs are not of human origin, “it is a matter for science. In any case, unidentified objects are a concern for aviation security.”

Another of the witnesses, Commander David Gravor, also a retired Navy pilot, testified how he witnessed in 2004 a UFO in the shape of a “tic tac”, a popular North American candy that looks like a pill, with flight capabilities impossible for US technology.

Graves said that if the United States has such technology, it “needs to be overseen” by lawmakers, who have to decide what is in the best interest of Americans.

Acute myeloid leukemia is a very common tumor with a high mortality rate.. Just over 50% of young adults survive after diagnosis, a figure that drops to less than 10% of those over 65 years of age.. “We have to be able to be precise in the treatments that we give to these patients, as is done in other tumors, such as in the breast, where biomarkers are used as a clue to adjust which therapy will respond best,” explains María Linares, researcher of the Hospital 12 de Octubre and the Complutense University of Madrid.

Up to 85% of patients could avoid the first line of treatment with chemotherapy and its side effects, opting for other more effective therapies if the alterations of some proteins will be determined to detect those who do not respond to standard therapy. “The current option is based mainly on the administration of cytarabine [an antineoplastic used in this type of hematological tumors discovered in 1970] along with other drugs,” explains Linares..

But the researcher qualifies that “although it is an effective drug, the vast majority of patients develop resistance, and very few of them survive in the long term. By being able to predict which patients are not going to respond, we would avoid chemotherapy and its side effects, such as anemia, thrombocytopenia and all the alterations that occur in blood cells”.

The prevalence of acute myeloid leukemia is high. Every year between three and four new cases of this blood tumor are diagnosed for every 100,000 inhabitants, according to the Spanish Association of People Affected by Lymphoma, Myeloma and Leukemia (AEAL).. The figure rises to 20 when it comes to people over 65, points out Linares. Since cancer cells spread rapidly through the blood it is an aggressive cancer.. This type of leukemia represents 40% of all leukemias, point out from the Josep Carreras Foundation.

Linares's team has published a study in Leukemia, a scientific publication of the Nature group, an investigation that paves the way for precision therapies in acute myeloid leukemia. Using cell models and patient samples, they have observed that proteins involved in gene processing (called splicing) are involved in cytarabine resistance..

“What we have done has been to take samples from patients who were resistant to treatment or not and compare them. So we have carried out studies at the messenger RNA level and discovered that mRNA splicing and the phosphorylation of serine-arginine (SR)-rich proteins were altered during cytarabine resistance,” summarizes the researcher..

The study is signed by his team and the main authors María Luz Morales and Roberto García-Vicente, both from the Research Institute of the Hospital 12 de Octubre i+12. Its objective is to put on the table an option within the range of personalized medicine available and design new treatments for refractory patients..

“We have developed a simple form, in the form of a smear, with which we could obtain this information from patients diagnosed with this type of leukemia,” explains Linares.. “Only a small amount of sample is needed. You just put a small droplet on a glass. We then stain the antibodies because they specifically recognize the proteins.”.

The October 12 researcher explains that they have series with samples of between 60-70 patients who could be classified as responders or not to standard treatment.. In the hospital it could be used “as a response biomarker”.

This same work has a second practical part, because they have also evaluated the efficacy and toxicity of possible new treatments.. Once it is known that there will be no response to the usual first line, a solution must be found

These are the names of the seven personalities that live inside Lore, a 35-year-old Mexican girl diagnosed with Dissociative Identity Disorder (DID) and who through her channel, Long Soul System, in which she accumulates more than 300,000 subscribers on Youtube, tries to let the world know about his mental illness.

DID is an unknown disorder for the population, despite affecting 2% of its totality and having had a strong presence in fiction, being the basis of the plot of stories such as The strange case of Dr.. Jekyll y Mr. Hyde, Psychosis or Multiple.

The mental alteration that Lore suffers, as explained by the Mayo Clinic on its website, “represents a disconnection and lack of continuity between thoughts, memories, environments, actions and identity”. Those who suffer from it, usually as a result of a trauma experienced during childhood, “escape from reality in involuntary and unhealthy ways, going so far as to experience periods of amnesia or develop alternative identities.”

For example, in the movie 'Multiple', released in 2016, the character played by James McAvoy has 23 personalities and behaves in an aggressive way, completely controlled by the identities that reside within him.. A perspective of the disorder that caused great controversy due to its stigmatization of mental illness. Thus, the International Society for the Study of Trauma and Dissociation decided to release a statement discrediting the vision of this disorder as something dangerous that is shown in the film and criticizing that it was done “at the expense of a vulnerable population that struggles to be recognized and receive the effective treatment they deserve.

That is precisely the battle that Lore from 'Long Soul System' is waging, who, in addition to giving visibility to the disorder through social networks, tries to destigmatize the people who suffer from it and prevent them from living the ordeal that she went through until find out what was wrong with him. “With what I do, I hope that DID can be diagnosed much earlier than it is currently done, because in my case it took a long time. I started going to therapy at the age of 6 and I've been going to a psychiatrist since I was 11, but I wasn't diagnosed with the disorder until I was 28, it's too long. Many things could work if dissociation were detected much earlier,” he says.

Lore (she does not give her full name because, as she explains, “people are very intense”) explains that her DID arose from the violence she suffered as a child, “a fairly common thing that many Mexican families go through.”. Her brain, to try to take refuge from this violence, began to dissociate to try to understand the situation that surrounded her, an experience experienced by many children, who must assimilate “the idea that their mother gives them love, but also hits them.” .

This situation, which occurred when he was 15 years old, “led to conversations with other alternative personalities through a notebook”, which he tried to hide while the disorder developed without pause and without exact knowledge about him.

Years, even decades, in which Lore was wandering between psychologists hearing diagnoses of “depression, panic attacks, agoraphobia, bipolarism, borderline personality disorder, obsessive-compulsive …”. Lore had a lot of misappraisals until she discovered the term dissociation herself and started researching it to not only find out her diagnosis, but also get a degree in psychology.

life with personalities

After this process, Lore is currently in the best moment of her life, “stable and lucid”. But he continues to live with seven identities within him, which fulfill a certain role within his total personality.

Among them, the four most characteristic are: Rayel who is 29 years old and is the hostess, the main character of the body; Antef, 32 years old, is the only man in the system and the main protector of the puzzle of personalities that make up Lore; Little Artist, who is a 3-year-old girl who, in addition to representing the most creative part of the system, has the ability to say what others are silent about, and finally, Alexxia, who, at 34, is the “persecutor” of the system, that is, that complicated identity, which the rest of the identities have already known how to control, but which has punished the rest for a long time, even causing self-harm to the body.

The personalities alternate with each other, through changes that can be born as a result of moments of stress and that Lore calls switches: “I really don't know very well how it works. It's like going to the front of a truck and switching drivers depending on what's going on around you.. When it does, it feels like passing out and can last anywhere from a few seconds to a few hours.”

They are alternations that arise at certain times, but the composition of the system is not similar to that of a queue in which the identities wait their turn to appear. If not, what Lore has inside is “a community” in which key decision-making, such as a move or the beginning of a relationship, is carried out through “a consensus among all”.

Lore, despite having managed to live with the disorder, continues to go to behavioral therapies, seeks professionals specialized in trauma, and has been taking antidepressants for years. Everything to achieve “a total fusion between the identities so that they remain in one and leave this disorder behind.”