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array:23 [ "pii" => "S2387020622005526" "issn" => "23870206" "doi" => "10.1016/j.medcle.2022.07.018" "estado" => "S300" "fechaPublicacion" => "2022-12-23" "aid" => "6053" "copyrightAnyo" => "2022" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Med Clin. 2022;159:598-603" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:18 [ "pii" => "S002577532200416X" "issn" => "00257753" "doi" => "10.1016/j.medcli.2022.07.010" "estado" => "S300" "fechaPublicacion" => "2022-12-23" "aid" => "6053" "documento" => "article" "crossmark" => 1 "subdocumento" => "ssu" "cita" => "Med Clin. 2022;159:598-603" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Artículo especial</span>" "titulo" => "Enfermedades hepáticas: un reto sanitario y social para la Europa del siglo XXI. 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"apellidos" => "Lazarus" ] 3 => array:2 [ "nombre" => "Bruno" "apellidos" => "Sangro" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2387020622005526" "doi" => "10.1016/j.medcle.2022.07.018" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020622005526?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S002577532200416X?idApp=UINPBA00004N" "url" => "/00257753/0000015900000012/v1_202212100523/S002577532200416X/v1_202212100523/es/main.assets" ] ] "itemSiguiente" => array:20 [ "pii" => "S238702062200554X" "issn" => "23870206" "doi" => "10.1016/j.medcle.2022.11.002" "estado" => "S300" "fechaPublicacion" => "2022-12-23" "aid" => "6076" "copyright" => "The Author(s)" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Med Clin. 2022;159:604-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "Alkaptonuria: Response to low-dose nitisinone in two patients with a new mutation" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "604" "paginaFinal" => "605" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Alcaptonuria: respuesta a dosis bajas de nitisinone en 2 pacientes con una mutación nueva" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1841 "Ancho" => 1500 "Tamanyo" => 153278 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Biochemical changes secondary to the treatment. Upper panel: urinary HGA excretion after nitisinone dosing. The dotted line marks the upper limit of the reference range, and the dashed line marks the 50 mg/24 h dosage level. Note the logarithmic scale. Lower panel: serum tyrosine levels after nitisinone dosing. The dotted line marks the upper limit of the reference range, and the dashed line marks the 600 μmol/L threshold.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Pat. 1: patient 1; Pat. 2: patient 2.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Nuria Puente, Domingo Gonzalez-Lamuño, Jose A. Riancho" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Nuria" "apellidos" => "Puente" ] 1 => array:2 [ "nombre" => "Domingo" "apellidos" => "Gonzalez-Lamuño" ] 2 => array:2 [ "nombre" => "Jose A." "apellidos" => "Riancho" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775322004481" "doi" => "10.1016/j.medcli.2022.08.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775322004481?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S238702062200554X?idApp=UINPBA00004N" "url" => "/23870206/0000015900000012/v2_202301310808/S238702062200554X/v2_202301310808/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2387020622005538" "issn" => "23870206" "doi" => "10.1016/j.medcle.2022.07.019" "estado" => "S300" "fechaPublicacion" => "2022-12-23" "aid" => "6073" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "rev" "cita" => "Med Clin. 2022;159:592-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Embolization of genicular arteries in patients with knee osteoarthritis as an alternative for refractory pain treatment: A systematic review" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "592" "paginaFinal" => "597" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Embolización de arterias geniculares en pacientes con osteoartrosis de rodilla como alternativa de tratamiento del dolor. Una revisión sistemática" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 794 "Ancho" => 1675 "Tamanyo" => 135002 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Flowchart of selection of studies included for analysis.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Kerbi Alejandro Guevara-Noriega, Raquel Chavez-Abiega, Juan Gabriel Castro-Rios" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Kerbi Alejandro" "apellidos" => "Guevara-Noriega" ] 1 => array:2 [ "nombre" => "Raquel" "apellidos" => "Chavez-Abiega" ] 2 => array:2 [ "nombre" => "Juan Gabriel" "apellidos" => "Castro-Rios" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775322004444" "doi" => "10.1016/j.medcli.2022.07.022" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775322004444?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020622005538?idApp=UINPBA00004N" "url" => "/23870206/0000015900000012/v2_202301310808/S2387020622005538/v2_202301310808/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>" "titulo" => "Liver diseases: A sanitary and social challenge for Europe in the XXI Century. Results of EASL-Lancet Comission" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "598" "paginaFinal" => "603" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Pere Ginès, Maria Buti, Jeffrey V. Lazarus, Bruno Sangro" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Pere" "apellidos" => "Ginès" "email" => array:1 [ 0 => "pgines@clinic.cat" ] "referencia" => array:5 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 4 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Maria" "apellidos" => "Buti" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 2 => array:3 [ "nombre" => "Jeffrey V." "apellidos" => "Lazarus" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] ] ] 3 => array:3 [ "nombre" => "Bruno" "apellidos" => "Sangro" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "aff0035" ] ] ] ] "afiliaciones" => array:7 [ 0 => array:3 [ "entidad" => "Servicio de Hepatología, Hospital Clínic de Barcelona, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD) del Instituto de Salud Carlos III, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Facultad de Medicina y Ciencias de la Salud, Universidad de Barcelona, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Unidad de Hepatología, Hospital Universitario Valle de Hebrón, Barcelona, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Instituto de Salud Global (ISGlobal), Hospital Clínic, Universidad de Barcelona, Barcelona, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Unidad de Hepatología, Clínica Universidad de Navarra, Pamplona, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Enfermedades hepáticas: un reto sanitario y social para la Europa del siglo XXI. Resultados de la Comisión EASL-Lancet" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1622 "Ancho" => 2926 "Tamanyo" => 469767 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Types of stigma and consequences of disease-related stigma, as well as examples of interventions. Reproduced with permission from Karlsen et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Liver diseases are very common and cause high morbidity and mortality, as well as a high use of healthcare resources.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Despite this, they have received little attention from the medical community, health authorities and the general public compared to other chronic diseases such as heart, lung or neurological diseases. This may be partly due to the stigma attached to people with liver disease because of its association with alcohol, drugs and obesity.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In 2019, chronic liver diseases caused 287,000 deaths in Europe, of which 63,500 were due to liver cancer. Moreover, liver disease is second only to ischaemic heart disease as a cause of working life years lost.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Excessive alcohol consumption, viral hepatitis, and metabolic syndrome are the most common causes of liver disease.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In order to focus attention on liver disease in Europe, the <span class="elsevierStyleItalic">European Association for the Study of the Liver</span> (EASL) and the journal <span class="elsevierStyleItalic">The Lancet</span> launched a Commission of experts from several countries, the results of which have recently been published.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This article aims to summarise the commission's findings and highlight some of the most relevant aspects.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Causes of liver diseases in Europe</span><p id="par0015" class="elsevierStylePara elsevierViewall">There are several risk factors for liver disease, which are summarized below.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Alcohol and liver disease</span><p id="par0020" class="elsevierStylePara elsevierViewall">Europe has the highest reported rates of alcohol consumption in the world, with alcohol being the most common cause of liver disease. Data from <span class="elsevierStyleItalic">Global Burden of Disease</span> (GBD) show that alcohol was responsible for approximately 580,000 deaths in 2019 (6.2% of all deaths in the World Health Organization [WHO] European region), although the actual mortality is probably higher. Alcohol-related liver disease contributes to at least 50% of cases of cirrhosis.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The damage caused by alcohol correlates with the volume and pattern of consumption, with an exponential relationship between the dose of alcohol consumed and liver disease. The evidence of the relationship between alcohol consumption and liver mortality shows the need to implement population-based interventions that reduce alcohol consumption.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Viral hepatitis and liver disease</span><p id="par0025" class="elsevierStylePara elsevierViewall">In Europe there are approximately 99,500 deaths annually due to hepatitis B and C, most of them due to cirrhosis. Ten of the 53 countries in the WHO European region are responsible for 75% of the viral hepatitis burden, with Georgia being the country with the highest prevalence. The prevalence of viral hepatitis varies from very low prevalences (<0.1% for hepatitis B virus [HBV] and <0.5% for hepatitis C virus [HCV]) in north-eastern European countries to very high (6%–8% for HBV and 3%–6% for HCV) in some eastern European countries.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> People who use recreational drugs have the highest prevalence. The introduction of hepatitis B vaccination programmes in the 1990s have shown their effect in decreasing the prevalence of hepatitis B in children under 10 years of age, but there is still a significant burden of disease in adults, particularly in some Eastern European countries. Hepatitis D, the most severe form of viral hepatitis, occurs in people with hepatitis B. Hepatitis D is decreasing in prevalence due to hepatitis B vaccination. Its prevalence is declining thanks to hepatitis B vaccination, but high rates of infection are still seen in older adults in some countries and in immigrants from countries with a high prevalence of hepatitis D. Hepatitis C has changed dramatically in Europe thanks to direct-acting oral antivirals. Its prevalence is decreasing due to micro-elimination policies and the greatest effects are seen in the reduction of decompensated liver disease and liver cancer forms of presentation. WHO's goal of eliminating viral hepatitis by 2030 requires public health policies aimed at increasing vaccination, diagnosis and treatment of hepatitis B and C.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Hepatitis E is an increasingly common cause of acute hepatitis, which can progress to chronic hepatitis in immunocompromised subjects. Hepatitis E is underreported since it is asymptomatic in many cases and not all European countries notify their cases.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Metabolic liver disease: a growing epidemic</span><p id="par0035" class="elsevierStylePara elsevierViewall">This non-alcoholic or metabolic fatty liver disease (NAFLD, <span class="elsevierStyleItalic">non-alcoholic fatty liver disease</span> or <span class="elsevierStyleItalic">MAFLD, metabolic-associated fatty liver disease</span> ) is expected to be the most common cause of advanced liver disease in the short- to medium-term if public health measures are not taken.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This entails a significant economic burden both in direct and indirect costs for society.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Metabolic liver disease is only one aspect of a more common systemic disease in people with type 2 diabetes and obesity that confers substantially higher morbidity and mortality in affected patients due to cardiovascular and hepatic causes.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Rare liver diseases</span><p id="par0045" class="elsevierStylePara elsevierViewall">Most liver diseases in children fall under the definition of rare liver diseases (prevalence less than 1 per 2000). Rare liver diseases in adults are mainly of autoimmune and metabolic genetic origin.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Despite their rarity, these diseases are responsible for a disproportionate number of liver transplants, reflecting the need for early diagnosis and effective treatment. The young age of presentation of many of these rare diseases poses a considerable challenge for patients and health systems, as do the ongoing costs of medical care.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Synergies and multiplicative damage of liver disease risk factors</span><p id="par0050" class="elsevierStylePara elsevierViewall">The risk factors for liver disease interact with and amplify each other. Obesity makes alcohol consumption much more dangerous, as it doubles the hepatotoxicity of alcohol and increases the risk of hepatocellular carcinoma. Alcohol also increases the risk of mortality from co-existing HCV infection. Unhealthy diet is another synergistic risk factor, which increases the burden of liver disease. Many European countries have seen a surprising increase in the consumption of ultra-processed foods, which are often characterized by low nutritional quality, high energy density and the presence of additives.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Inequalities and stigmatization</span><p id="par0055" class="elsevierStylePara elsevierViewall">In terms of health and disease, the liver is a highly stigmatized organ. Liver disease is commonly linked to excessive alcohol consumption and NAFLD to obesity, both highly stigmatized situations.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> In addition, people at higher risk of having or developing liver disease often belong to stigmatised groups, such as intravenous drug users, prisoners and migrants from areas where viral hepatitis is highly prevalent.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Stigma can exacerbate existing inequalities. According to the EASL-Lancet Commission, stigma leads to discrimination, reduces resource allocation and deters care-seeking, worsening clinical outcomes and increasing health inequalities.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The NAFLD public health consensus statement reiterated that stigma can be a major barrier when addressing health issues.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Stigmatisation also worsens social inequalities by affecting intra- and interpersonal relationships, which can encourage high-risk behaviours and obstruct educational and employment opportunities.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Combating liver disease will require addressing stigma at all levels, including public stigma (e.g., stereotypes among the general public), structural stigma (e.g., negative nomenclature and discriminatory health policies) and stigma in the healthcare environment (e.g., stereotypes among staff), which can lead to self-stigma (i.e., internalised stigma) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The EASL-Lancet Commission recommends initiatives to combat all types of stigmas targeting people at increased risk of having or developing liver disease, using multi-level interventions and involving all stakeholders. To address stigma in healthcare settings, it is advisable to have trained anti-stigma health professionals, evidence-based and contact with community members who share their experiences with stigma and its consequences. To address self-stigma, it is suggested to provide patient education involving caregivers, to lead to empowerment and support participation in health care, and to adopt gender-sensitive initiatives where possible, as women are more concerned than men about stigmatising attitudes. To address structural stigma, it is recommended to remove stigmatising terms from nomenclature, such as alcoholic, and to name situations reflecting the clinical disease rather than using obsolete behavioural or histopathological terminology. Such a movement already exists with NAFLD to reach consensus on a nomenclature change.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Taking into account the impact of disorders such as NAFLD, which is estimated to affect 25% of the world's adult population,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and hepatitis C virus infection, with around 57 million cases worldwide,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> addressing stigma is essential. Only by addressing this issue will there be a change in the way liver disease is perceived and therefore treated.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">From late to early diagnosis of liver cirrhosis based on population or risk group screening</span><p id="par0075" class="elsevierStylePara elsevierViewall">Most cases of liver cirrhosis are diagnosed when the disease is very advanced, either due to the existence of portal hypertension that causes thrombocytopenia or leukopenia or due to the development of complications such as ascites or gastrointestinal bleeding due to oesophageal varices. At this stage, liver fibrosis is irreversible, and the disease often progresses inexorably with progressively more severe complications leading to death unless a liver transplant is performed.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Some patients develop liver cancer, especially hepatocarcinoma, and also die, unless they are transplanted. It is clear that the current paradigm based on late diagnosis of cirrhosis when patients present to the health system with severe complications of the disease is totally inadequate because it is resource intensive, results in poor quality of life for patients and has unacceptably high mortality rates. A radical change in the diagnostic paradigm is therefore required for most chronic liver diseases so that they can be diagnosed at an early stage when liver fibrosis is still reversible and, in many cases, avoid progression to end-stage disease.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Several studies published in recent years have shown that the best way for early detection of chronic liver diseases, especially those caused by NAFLD and alcohol consumption, is based on the detection of liver fibrosis that can be performed by non-invasive methods without the need for liver biopsy. These include serological methods based on the combination of several simple laboratory variables (e.g., FIB-4 indices or <span class="elsevierStyleItalic">NAFLD fibrosis score</span>) or more complex ones (e.g., the <span class="elsevierStyleItalic">Enhanced Liver Fibrosis</span> [ELF] tests, Fibrotest), or on imaging methods (such as transient elastography or magnetic resonance elastography).<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The accuracy of these methods for the diagnosis of liver fibrosis is variable, with magnetic resonance elastography being the most accurate method followed by transient elastography.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> However, both of these methods are expensive and not generally available in primary care, where early detection of liver disease should be performed.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Population studies conducted so far in Europe indicate a prevalence of moderate to advanced liver fibrosis (corresponding to fibrosis grades two to four on a classification from 0 - no fibrosis - to 4 - liver cirrhosis) of 3% of a randomly identified adult population (aged 40–80 years) and 18%–27% of the adult population with risk factors for liver disease.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The prevalence of occult liver cirrhosis ranges between 0.26% and 0.75% of the general population.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The most common aetiology of liver disease in population screening studies is NAFLD.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Initiatives in some countries around the world are investigating the efficacy of population-based fibrosis screening in the early detection of silent chronic liver disease. Among them is the <span class="elsevierStyleItalic">LiverScreen</span><a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> project, a European project that aims to evaluate more than 70,000 subjects from different European countries to determine the efficacy and usefulness of population-based screening for liver fibrosis. If proven useful, population-based screening would radically change the stage at which we treat patients with chronic liver disease and lead to an increase in the number of patients diagnosed and treated at earlier stages, reducing the number of patients diagnosed with advanced cirrhosis. All this represents a great challenge not only for professionals but also for health systems.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Summary of recommendations</span><p id="par0095" class="elsevierStylePara elsevierViewall">The 10 recommendations of the EASL-Lancet Commission aim to reduce the impact of liver disease on people's lives and the countries they live in (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). In this review we have focused on those measures that seem to us to be particularly relevant in Spain.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">The personal, social and economic cost of treating liver diseases is extremely high for cirrhosis and cancer. The long natural history of these diseases provides a great opportunity for early detection (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Early detection in the general population should be done in primary care, and primary care providers should be aware of the problem, know the decision algorithms and use them. Simple and inexpensive tests are available to detect advanced liver fibrosis and cirrhosis, including a number of algorithms that allow estimation of fibrosis risk from blood tests; and also, the non-invasive measurement of liver stiffness by transient elastography which has superior accuracy.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The FIB-4 index (based on age and AST, ALT and platelet levels) is one of them and testing laboratories should automatically provide this or other markers of liver fibrosis. However, recent reports suggest that the accuracy of FIB-4 in identifying significant liver fibrosis in population screening is limited, with a high false positive and negative rate, and that potentially more accurate methods need to be investigated.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Once cases with significant fibrosis have been identified, priority should be given to the management of the most advanced or complex cases by specialists in the hospital setting, leaving the less advanced cases under the control of primary care. In addition, it is important to design advertising and education campaigns that improve liver health literacy, especially among the most vulnerable. The challenges and difficulties in making this paradigm shift a reality are many, not the least of which is the precarious situation that the COVID-19 pandemic has revealed in our primary care system, with unmanageable and underpaid workloads, insufficient capacities and restricted access to hospital care support.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">It is important and feasible to invest in scaling up viral hepatitis screening in selected settings (primary care, drug dependence centres and prisons). Our country has been a pioneer in this regard, and the Strategic Plan to Address Hepatitis C (2015) is proving successful. At-risk groups are persons who: (a) have used snorted or injected drugs or received blood products before 1990; (b) have undergone health interventions, tattooing or <span class="elsevierStyleItalic">piercings</span> without appropriate monitoring; (c) have had unsafe sex; (d) are on haemodialysis or infected with human immunodeficiency virus (HIV) or HBV; (e) are prison inmates; and (f) are health personnel exposed to biohazardous procedures.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Education is a pillar of any strategy and scientific societies with an interest in liver diseases (hepatology, family and community medicine, nursing, and other specialties) should collaborate in developing a curriculum in hepatology for primary care. The aim is to establish clear recommendations on the co-management of patients with liver disease by primary care physicians, specialists and specialist nurses and to promote the encouraged collaboration of these specialists in lifestyle and risk factor modification, viral hepatitis elimination, screening for cirrhosis and co-morbidities, and palliative care in advanced disease.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The committee further proposes that all non-viral liver diseases should be classified as non-communicable diseases (NCDs). This will help to integrate them into a broader and more comprehensive chronic care model, including primary care and a liver perspective. It is time to include liver diseases within the spectrum of NCDs related to metabolic disorders and to create platforms for collaborative work, which will enhance the collective effort of multiple stakeholders from various specialties and sectors of research and healthcare. And not only in primary care: we must advocate organisational policies in hospitals that oppose the siloed work of specialist doctors. Screening programmes for neonatal and hereditary liver disease must be established, and the centralisation of medical and surgical care for rare liver diseases must be encouraged. Similarly, legislative protection for specific groups, such as immigrants and children, should be promoted and educational interventions for staff working in chronic care should be put in place to combat age discrimination.</p><p id="par0120" class="elsevierStylePara elsevierViewall">As described above, reducing stigma and discrimination towards people at risk of liver disease requires a combination of interventions targeting multiple layers of stigma, in particular stigma in healthcare settings, structural stigma and self-stigma.</p><p id="par0125" class="elsevierStylePara elsevierViewall">On alcohol consumption, one of the most important causes of preventable chronic liver disease, the Commission recommends the introduction of a minimum price of 1/cL of pure alcohol in all European countries. Equally important is to put in place strategies that aim to ensure that people who consume alcohol achieve a level of consumption that mitigates harm to their health.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Advertising has a notable effect on the consumption of alcohol, beverages and ultra-processed foods high in sugar among adults and children. Child-targeted advertising on mobile phones by digital media and social networks has a very harmful effect. The experience of the tobacco industry has shown that the only effective means of protecting children is a total ban on this advertising.</p><p id="par0135" class="elsevierStylePara elsevierViewall">But preventing liver disease requires getting the food industry to lead a reformulation of foods. The availability of low-cost healthy food should be facilitated, proper food labelling promoted, and food literacy increased at community level. Tax money related to ultra-processed foods and foods high in fat, salt and sugar should be spent on minimising social inequalities by subsidising healthy foods, or prevention measures ranging from nutrition to physical activity programmes and anti-stigma interventions.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Drug access cannot be limited in the treatment of viral hepatitis, where the benefit of eradication is enormous. Removing economic barriers, putting in place a monitoring system to simplify access to antivirals in order to reduce gaps for specific groups, and establishing mechanisms for prescribing C virus therapy in health centres are all important actions. On the first issue, the Commission advocates a series of ambitious measures. One is to make public the actual prices negotiated in all 44 countries in Europe, and to give all countries access to data on the most commonly used combinations, as keeping actual prices confidential reduces incentives. On the other hand, as seen with COVID-19, pooled procurement should be a priority in Europe and having pooled procurement mechanisms would make antivirals available at a more affordable price.</p><p id="par0145" class="elsevierStylePara elsevierViewall">Finally, to combat pseudo-protectionist arguments, which favour the exclusion of specific groups and obstruct population-based policies to reduce liver disease mortality, the commission calls for coordinated and systematic public policy. Governments should prioritise the harmonisation of all forms of public health intervention across Europe with a particular emphasis on vulnerable groups, such as children, intravenous drug users, migrants and the poor. These include using taxation to subsidise health services and increase access to healthy foods; implementing a system to monitor disparities in access to specialised care for patients with cirrhosis; tailoring health information to different populations; creating uniform legislation in European countries to restrict aggressive advertising and marketing, especially among less affluent populations and children; establishing mechanisms to reward industry initiatives for healthy food reformulation; and convincing policy makers and the public that food and drink intake is not really a matter of free choice, but is strongly influenced by the actions of the food industry, driven by economic interests.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Future perspectives</span><p id="par0150" class="elsevierStylePara elsevierViewall">In recent decades, we have witnessed hepatology transform from one field of therapeutic nihilism into one with some of the greatest successes of modern medicine, including a cancer vaccine (in the form of prevention of hepatocellular carcinoma as a complication of hepatitis B) and the first chronic viral infection to be cured by oral drugs (hepatitis C). One of the biggest challenges for the future is that improvements in the diagnosis and care of liver disease will not succeed in reducing the burden of premature mortality unless they are accompanied by an effort to target the most disadvantaged groups in society.</p><p id="par0155" class="elsevierStylePara elsevierViewall">The focus must continue to move towards promoting liver health and diagnosing liver disease at much earlier stages, including through primary care. This approach will require the development of interdisciplinary relationships and multiprofessional teams supported by electronic systems and telemedicine. A change is needed in the way health care is financed and reimbursed, which is primarily a political problem. Until this issue is resolved, health inequalities will remain a major problem.</p><p id="par0160" class="elsevierStylePara elsevierViewall">While prevention and early detection are key, there is no getting away from the fact that advanced disease needs to be addressed in the best possible way. This is especially important in a situation in which the European population (and the Spanish population is no exception) is aging more than any other in the rest of the world. The development of effective therapies for chronic liver disease is advancing at a rapid pace. This includes systemic cancer therapy, minimally invasive liver surgery, or increased access to liver transplantation through donation after cardiac arrest, living donor or auxiliary transplantation, and liver support devices. Thanks to them, patients with advanced liver disease live longer and better. Providing access to these therapies to all people on equal terms and with the necessary speed is an unavoidable responsibility.</p><p id="par0165" class="elsevierStylePara elsevierViewall">Finally, it should be noted that liver health is a window into the general health challenges of 21st century Europe. Risk factors for the most common liver diseases - alcohol, obesity and intravenous drug use - reflect behaviours and situations that are the consequence of unhealthy environments and inequalities. Tackling these problems requires bold and far-reaching public health measures that will undoubtedly benefit the overall health of citizens.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Funding</span><p id="par0170" class="elsevierStylePara elsevierViewall">PG has the support of the following projects: <span class="elsevierStyleGrantSponsor" id="gs0005">LiverHope (EC-H2020)</span><span class="elsevierStyleGrantNumber" refid="gs0005">731875</span> and <span class="elsevierStyleGrantSponsor" id="gs0010">LiverScreen (EC-H2020)</span><span class="elsevierStyleGrantNumber" refid="gs0010">847989</span>, <span class="elsevierStyleGrantNumber" refid="gs0015">FisPlat 20308</span> funded by <span class="elsevierStyleGrantSponsor" id="gs0015">EITH</span> and co-funded by the <span class="elsevierStyleGrantSponsor" id="gs0020">European Union</span> and <span class="elsevierStyleGrantNumber" refid="gs0025">FIS PI20/00579</span> funded by the <span class="elsevierStyleGrantSponsor" id="gs0025">Carlos III Health Institute (ISCIII)</span> and co-funded by the <span class="elsevierStyleGrantSponsor" id="gs0030">European Union</span>. JVL acknowledges the support to ISGlobal from the <span class="elsevierStyleGrantSponsor" id="gs0035">Spanish Ministry of Science, Innovation and Universities</span> through the “Severo Ochoa 2019-2023 Center of Excellence” Program (<span class="elsevierStyleGrantNumber" refid="gs0035">CEX2018-000806-S</span>) and from the <span class="elsevierStyleGrantSponsor" id="gs0040">Government of Catalonia</span> through the CERCA Program.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0175" class="elsevierStylePara elsevierViewall">PG reports investigator-initiated grants and advisory boards from Grifols, investigator-initiated grants and advisory boards from Gilead Sciencies, investigator-initiated grant from Mallinckrodt, advisory board for Promethera, advisory board for Martin-Pharmaceuticals, research grants from Ferring Pharmaceuticals, grants and advisory board from Sequana and fees from Pfizer for a conference.</p><p id="par0180" class="elsevierStylePara elsevierViewall">MB received honoraria for conferences, presentations, speaking, manuscript writing, or educational activities from Gilead Sciences and AbbVie.</p><p id="par0185" class="elsevierStylePara elsevierViewall">JVL received grants or contracts from AbbVie, Gilead Sciences, Merck Sharp & Dohme to his institution, and payment or honoraria for lectures, presentations, being a speaker, writing manuscripts or educational events from AbbVie, Gilead Sciences, Intercept, Janssen and Merck Sharp & Dohme, outside of the submitted work.</p><p id="par0190" class="elsevierStylePara elsevierViewall">BS received research grants (to the institution) from Bristol Myers Squibb and Sirtex Medical. Advisory fees from Adaptimmune, AstraZeneca, Bayer, Bristol Myers Squibb, BTG, Sirtex Medical, Terumo, H3 Biomedicine, Incyte, Ipsen, Lilly, and Roche. Fees for presentations or educational events from Bayer, Bristol Myers Squibb, Sirtex Medical, Terumo, Incyte, and Ipsen.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:3 [ "identificador" => "sec0010" "titulo" => "Causes of liver diseases in Europe" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Alcohol and liver disease" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Viral hepatitis and liver disease" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Metabolic liver disease: a growing epidemic" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Rare liver diseases" ] ] ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Synergies and multiplicative damage of liver disease risk factors" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Inequalities and stigmatization" ] 4 => array:2 [ "identificador" => "sec0045" "titulo" => "From late to early diagnosis of liver cirrhosis based on population or risk group screening" ] 5 => array:2 [ "identificador" => "sec0050" "titulo" => "Summary of recommendations" ] 6 => array:2 [ "identificador" => "sec0055" "titulo" => "Future perspectives" ] 7 => array:2 [ "identificador" => "sec0060" "titulo" => "Funding" ] 8 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflicts of interest" ] 9 => array:2 [ "identificador" => "xack649670" "titulo" => "Acknowledgements" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1622 "Ancho" => 2926 "Tamanyo" => 469767 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Types of stigma and consequences of disease-related stigma, as well as examples of interventions. Reproduced with permission from Karlsen et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1611 "Ancho" => 2930 "Tamanyo" => 335921 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Diagram of stratification of people at risk of liver disease for non-hepatologists. Reproduced with permission from Karlsen et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Reproduced with permission from Karlsen et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p>" "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1. Establish an efficient process for the early detection of liver disease among people at high risk of liver disease in the general population, using a simple algorithm based on the analysis of standardised liver tests and scores such as the FIB-4 to identify patients with advanced fibrosis. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2. Invest resources to scale up case finding and screening for viral hepatitis in selected (e.g., primary care serving immigrants, harm reduction/drug services and prisons) and broader community settings (e.g., coupled with SARS-CoV-2-antibody testing), with reflex viremia testing for those antibody positive. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3. Have scientific societies (hepatology, family and community medicine, nursing, and other medical specialties) collaborate to develop a curriculum for primary care hepatology, with an emphasis on the dissemination of simplified, patient-centred clinical pathways and multimorbidity models of care. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4. To have all non-viral liver diseases classified as non-communicable diseases (NCDs) to enable the common characteristics of NCDs to drive a chronic care network that includes specialists, primary care physicians and nurses trained in the management of obesity, diabetes, liver disease, cardiovascular disease and chronic kidney disease, to facilitate engagement in liver patient care across classical medical specialty boundaries. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5. Launch a range of initiatives to oppose all forms and sources of stigma and discrimination of people at risk of or with liver disease using multilevel interventions which also involve peers and members of community. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6. Promote the public disclosure of pricing information of approved antiviral drugs currently used to treat viral hepatitis in Europe, which would reinforce the WHO and World Health Assembly resolution to improve the transparency, and fairness of market prices for medicines. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7. Urge central and Autonomous Community governments to introduce uniform and effective policies to reduce the harmful use of alcohol; specifically, the Commission recommends that a minimum price of 1/cL of pure alcohol is introduced in all European countries and that this minimum price be accompanied by appropriate increases in alcohol taxation to ensure that the windfall to retailers is returned to government finances. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8. Draw attention to the harmful impact of personalized advertising of alcohol and ultra-processed foods and beverages with a high sugar content on children through mobile phones by digital media and social networks. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9. Call for policy measures to promote industry-led food reformulation and minimizing social inequities by subsidizing healthy foods. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10. Call for a co-ordinated and systematic public health case to be made to rebut the “nanny state” and “pseudo-protective” arguments, which favour exclusion of specific groups and obstruct population level policies to reduce liver disease mortality. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">EASL-Lancet Commission Recommendations.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Burden of liver disease in Europe: epidemiology and analysis of risk factors to identify prevention policies" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Pimpin" 1 => "H. 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