AGILE SCORES IN MASLD AND ALD: EXTERNAL VALIDATION AND THEIR UTILITY IN CLINICAL ALGORITHMS

BACKGROUND

Agile scores, including liver stiffness measurements (LSM) and routine clinical/laboratory biomarkers, have been developed for advanced fibrosis (F≥3) and cirrhosis, respectively, in patients with metabolic-associated steatotic liver disease (MASLD). We independently validated the diagnostic accuracy of these scores in MASLD, alcohol-related liver disease (ALD) and chronic hepatitis B or C (CHB/C) and assessed them in clinical algorithms with FIB-4 and LSM.

METHODS

We included 4,243 patients (MASLD:912, ALD:386, CHB:597, CHC:2348) with LSM, liver biopsy and laboratory tests within 6 months. FIB-4, Agile 3+ and Agile 4 scores were calculated.

RESULTS

For F≥3, diagnostic accuracy of Agile 3+ and LSM were similar in MASLD (AUC: 0.86 vs 0.86, P=0.831) and ALD (0.92 vs 0.94, P=0.123). For cirrhosis, Agile 4 was similar to LSM in MASLD (0.89 vs 0.90, P=0.412) and ALD (0.94 vs 0.95, P=0.513). Agile 3+/4 performed worse than LSM in CHB/C. Using predefined dual thresholds of 90% Se/Sp, correct classification rates in MASLD were 66% vs 61% using Agile 3+ vs LS dual cut-offs and 71% vs 67% in ALD. When using Agile 3+ or LSM as a second step after FIB-4>1.3, correct classification rates were higher with Agile 3+ than LSM, both for MASLD (75% vs 71%) and for ALD patients (76% vs 72%) with fewer indeterminate results. Positive agreement of LSM and Agile 3+/4 significantly increased the specificity of a diagnosis of advanced fibrosis/cirrhosis.

CONCLUSION

Agile 3+ and Agile 4 have equal diagnostic accuracy with LSM in both MASLD and ALD but result in fewer indeterminate results. Sequential use of FIB-4 and Agile 3+/4 or concurrent Agile 3+/4 and LSM can be used to further optimize F≥3 diagnosis.

Quick and easy assessment of sarcopenia in cirrhosis: Can ultrasound be the solution?

Cirrhosis is frequently associated with sarcopenia, with reported rates of over 80% in patients with decompensated alcohol-related liver disease. Sarcopenia negatively impacts the prognosis of cirrhotic patients and affects the response to treatment of patients with hepatocellular carcinoma (HCC). For these reasons, identifying an easy-to-perform method to assess sarcopenia in is a key element in the optimization of care in this patient population. Assessment of muscle mass by computed tomography is considered the standard of care for the diagnosis of sarcopenia, but exposure to radiation and high costs limit its application in this setting, especially for repeated assessments. We believe that ultrasound, a cheap and harmless technique also used for HCC screening in cirrhotic patients, could have an expanding role in the diagnosis and follow-up of sarcopenia in these patients.

NAIF: A novel artificial intelligence-based tool for accurate diagnosis of stage F3/F4 liver fibrosis in the general adult population, validated with three external datasets

OBJECTIVE

The purpose of this study was to determine the effectiveness of a new AI-based tool called NAIF (NAFLD-AI-Fibrosis) in identifying individuals from the general population with advanced liver fibrosis (stage F3/F4). We compared NAIF's performance to two existing risk score calculators, aspartate aminotransferase-to-platelet ratio index (APRI) and fibrosis-4 (Fib4).

METHODS

To set up the algorithm for diagnosing severe liver fibrosis (defined as Fibroscan® values E ≥ 9.7 KPa), we used 19 blood biochemistry parameters and two demographic parameters in a group of 5,962 individuals from the NHANES population (2017-2020 pre-pandemic, public database). We then assessed the algorithm's performance by comparing its accuracy, precision, sensitivity, specificity, and F1 score values to those of APRI and Fib4 scoring systems.

RESULTS

In a kept-out sub dataset of the NHANES population, NAIF achieved a predictive precision of 72 %, a sensitivity of 61 %, and a specificity of 77 % in correctly identifying adults (aged 18-79 years) with severe liver fibrosis. Additionally, NAIF performed well when tested with two external datasets of Italian patients with a Fibroscan® score E ≥ 9.7 kPa, and with an external dataset of patients with diagnosis of severe liver fibrosis through biopsy.

CONCLUSIONS

The results of our study suggest that NAIF, using routinely available parameters, outperforms in sensitivity existing scoring methods (Fib4 and APRI) in diagnosing severe liver fibrosis, even when tested with external validation datasets. NAIF uses routinely available parameters, making it a promising tool for identifying individuals with advanced liver fibrosis from the general population. Word count abstract: 236.

An LCA answer to the mixed plastics waste dilemma: Energy recovery or chemical recycling?

The study focuses on mixed plastics waste (MPW), whose complex and unpredictable composition (due to high polymer heterogeneity, additives, and contaminants) makes its valorisation a true technical, environmental, economic, and regulatory challenge. Chemical recycling by means of advanced thermochemical treatments (ATT) could be a successful strategy, able to support the transition from a carbon intensive to a carbon negative sector, and alternative to the current treatments of energy recovery or mechanical downcycling. Some of these ATTs provide an efficient recovery of valuable resources, such as fuels and chemicals, but their role is mainly limited by time necessary to complete the process optimization and implement the required infrastructures. A reliable identification of the best alternatives is thus crucial. A specific LCA approach quantifies the environmental performances of a selected set of ATT technologies for resource recovery from MPW. It includes plastics-to-energy, by combustion or gasification; plastics-to-methane and plastics-to-hydrogen, by gasification; and plastics-to-oil, by thermal pyrolysis. The results highlight the crucial role of carbon capture and storage (CCS) units, which partially reduces that of the specific thermochemical treatment. The best performances, particularly for Climate Change category, are those of the MPW-to-hydrogen by gasification, followed by those of MPW-to-energy by combustion or gasification, all equipped with CCS. The sensitivity analysis considers the evolution of the European energy mix, characterised by a larger utilisation of renewable energy sources, and highlights the corresponding increased sustainability of chemical recycling by ATTs. This suggests that the MPW dilemma should be definitively solved in a close future.

Transjugular intrahepatic Porto-systemic shunt positively influences the composition and metabolic functions of the gut microbiota in cirrhotic patients

BACKGROUND & AIMS

Cirrhosis and its complications may affect gut microbiota (GM) composition. Transjugular intrahepatic portosystemic shunt (TIPS) represents the most effective treatment for portal hypertension (PH). We aimed to evaluate whether TIPS placement modifies GM composition and metabolic function.

METHODS

A compositional and functional GM analysis was prospectively performed in 13 cirrhotic patients receiving TIPS. Patients receiving systemic or non-absorbable antibiotics for any indications were excluded. Fecal samples were collected before and three months after TIPS. GM was analyzed by 16S ribosomal RNA sequencing. Small- and medium-chain fatty acids (SCFAs and MCFAs, respectively) were measured by gas chromatography/mass spectrometry.

RESULTS

TIPS placement resulted in a mean 48% reduction in portal-caval pressure gradient. No recurrence of PH related complications was observed. After TIPS, increased levels of Flavonifractor spp. (p = 0.049), and decreased levels of Clostridiaceae (p = 0.024), these latter linked to abdominal infections in cirrhotic patients, were observed. No differences were found in the SCFAs signature while analysis of MCFA profiles showed a decreased abundance of pro-inflammatory isohexanoic (p<0.01), 2-ethylhexanoic (p<0.01) and octanoic acids (p<0.01) after TIPS.

CONCLUSION

Correction of PH following TIPS results in modifications of GM composition which could be potentially beneficial and reduces the levels of fecal pro-inflammatory MCFAs.

Mortality after transjugular intrahepatic portosystemic shunt in older adult patients with cirrhosis: A validated prediction model

BACKGROUND AND AIMS

Implantation of a transjugular intrahepatic portosystemic shunt (TIPS) improves survival in patients with cirrhosis with refractory ascites and portal hypertensive bleeding. However, the indication for TIPS in older adult patients (greater than or equal to 70 years) is debated, and a specific prediction model developed in this particular setting is lacking. The aim of this study was to develop and validate a multivariable model for an accurate prediction of mortality in older adults.

APPROACH AND RESULTS

We prospectively enrolled 411 consecutive patients observed at four referral centers with de novo TIPS implantation for refractory ascites or secondary prophylaxis of variceal bleeding (derivation cohort) and an external cohort of 415 patients with similar indications for TIPS (validation cohort). Older adult patients in the two cohorts were 99 and 76, respectively. A cause-specific Cox competing risks model was used to predict liver-related mortality, with orthotopic liver transplant and death for extrahepatic causes as competing events. Age, alcoholic etiology, creatinine levels, and international normalized ratio in the overall cohort, and creatinine and sodium levels in older adults were independent risk factors for liver-related death by multivariable analysis.

CONCLUSIONS

After TIPS implantation, mortality is increased by aging, but TIPS placement should not be precluded in patients older than 70 years. In older adults, creatinine and sodium levels are useful predictors for decision making. Further efforts to update the prediction model with larger sample size are warranted.

Evaluating the best treatment for multifocal hepatocellular carcinoma: A propensity score-matched analysis

BACKGROUND

Hepatocellular carcinoma (HCC) is a common tumour often diagnosed with a multifocal presentation. Patients with multifocal HCC represent a heterogeneous group. Although Trans-Arterial ChemoEmbolization (TACE) is the most frequently employed treatment for these patients, previous data suggested that liver resection (LR) could be a safe and effective procedure.

AIM

To compare LR and TACE in patients with multifocal HCC in terms of procedure-related morbidity and oncologic outcomes.

METHODS

All patients with multifocal HCC who underwent LR or TACE as the first procedure between May 2011 and March 2021 were enrolled. The decision to perform surgery or TACE was made after a multidisciplinary team evaluation. Only patients in Child-Pugh class A or B7 and stage B (according to the Barcelona Clinic Liver Cancer staging system, without severe portal hypertension, vascular invasion, or extrahepatic spread) were included in the final analysis. Propensity score matching was used to adjust the baseline differences between patients undergoing LR and the TACE group [number and diameter of lesions, presence of cirrhosis, alpha-fetoprotein (AFP) levels, and Model for End-Stage Liver Disease score]. The Kaplan-Meier method was used to estimate overall survival (OS) and disease-free survival (DFS). The outcomes of LR and TACE were compared using the log-rank test.

RESULTS

After matching, 30 patients were eligible for the final analysis, 15 in each group. Morbidity rates were 42.9% and 40% for LR and TACE, respectively (P = 0.876). Median OS was not different in the LR and TACE groups (53 mo vs 18 mo, P = 0.312), while DFS was significantly longer with LR (19 mo vs 0 mo, P = 0.0001). Subgroup analysis showed that patients in the Italian Liver Cancer (ITA.LI.CA) B2 stage, with AFP levels lower than 400 ng/mL, less than 3 lesions, and lesions bigger than 41 mm, benefited more from LR in terms of DFS. Patients classified as ITA.LI.CA B3, with AFP levels higher than 400 ng/mL and with more than 3 lesions, appeared to receive more benefit from TACE in terms of OS.

CONCLUSION

In a small cohort of patients with multifocal HCC, LR confers longer DFS compared with TACE, with similar OS and post-procedural morbidity.

Portosystemic shunt is an effective treatment for complications of portal hypertension in hepatic myeloid metaplasia and improves nutritional status

In patients affected by myelofibrosis with hepatic myeloid metaplasia (HMM), portal hypertension (PHT) complications may develop. In this case series, we analysed the efficacy and safety of transjugular portosystemic shunt (TIPS) in the treatment of PHT-related complications and its effects on the nutritional status. Six patients were evaluated and the average follow-up period after TIPS was 33 (IQR 5) months. None of the patients developed hepatic failure, nor any recurrence of variceal bleeding was recorded. No additional paracentesis or endoscopic prophylactic treatment for PHT-related complications were required. In all subjects, the average dose of diuretics was almost halved three months after TIPS. Three patients died during the follow-up, but none for liver-related causes. All patients showed an improvement in the global nutritional status. In conclusion, TIPS represent an effective and safe treatment option for patients affected by complications of PHT secondary to HMM and drives to an improvement of the nutritional status.

How to enhance the environmental sustainability of WEEE plastics management: An LCA study

A new management scheme of plastics from waste of electrical and electronic equipment (WEEE), which includes novel treatments of sorting, dissolution/precipitation, extrusion, catalytic pyrolysis, and plastic upgrading, is proposed. Its environmental performances are quantified by an attributional Life Cycle Assessment and compared with those of European currently adopted schemes, which include conventional mechanical recycling and thermal treatments as well as improper options of dumping and open burning, largely applied to WEEE plastics exported to developing countries. The proposed innovative scheme greatly enhances the environmental sustainability of WEEE plastics management, by increasing the annual amounts of polymers sent to recycling (from 390 kt/y up to 530 kt/y), decreasing residues to be sent to combustion (from 360 kt/y up to 60 kt/y), and reducing the potential impacts of all the midpoint categories under analysis (up to 580% for that of Global Warming). These results are mainly related to the adoption of a dissolution/precipitation process, which allows recovering target polymers such as ABS, HIPS and PC, with improvements in terms of Global Warming, Non-Carcinogens, and Carcinogens equal to 246%, 69% and 35%, even when the stages of polymer upgrading and catalytic pyrolysis are not included in the analysis. The sensitivity analysis shows that advantages of the new approach substantially disappear if the awful contributions of exportation outside Europe are taken into account. This clearly indicates that the first step to enhance the sustainability of WEEE plastics management is a strong limitation of improper treatments applied to exported wastes.

About the environmental sustainability of the European management of WEEE plastics

A huge increase of waste of electrical and electronic equipment (WEEE) is observing everywhere in the world. Plastic component in this waste is more than 20% of the total and allows important environmental advantages if well treated and recycled. The resource recovery from WEEE plastics is characterised by technical difficulties and environmental concerns, mainly related to the waste composition (several engineering polymers, most of which containing heavy metals, additives and brominated flame retardants) and the common utilisation of sub-standard treatments for exported waste. An attributional Life Cycle Assessment quantifies the environmental performances of available management processes for WEEE plastics, those in compliance with the European Directives and the so-called substandard treatments. The results highlight the awful negative contributions of waste exportation and associated improper treatments, and the poor sustainability of the current management scheme. The ideal scenario of complete compliance with European Directives is the only one with an almost negligible effect on the environment, but it is far away from the reality. The analysed real scenarios have strongly negative effects, which become dramatic when exportation outside Europe is included in the waste management scheme. The largely adopted options of uncontrolled open burning and illegal open dumping produce huge impacts in terms of carcinogens (3.5·10⁺⁷ and 3.6·10⁺⁴ person⋅year, respectively) and non-carcinogens (1.7·10⁺⁸ and 2.0·10⁺⁶ person⋅year) potentials, which overwhelm all the other potential impacts. The study quantifies the necessity of strong reductions of WEEE plastics exportation and accurate monitoring of the quality of extra-Europe infrastructures that receive the waste.

Refining the Baveno VI elastography criteria for the definition of compensated advanced chronic liver disease

BACKGROUND

The Baveno VI consensus proposed a dual liver stiffness (LS) by transient elastography threshold of <10 and >15 kPa for excluding and diagnosing compensated advanced chronic liver disease (cACLD) in the absence of other clinical signs. Herein, we aimed to validate these criteria in a real-world multicentre study.

METHODS

We included 5,648 patients (mean age 51 ± 13 years, 53% males) from 10 European liver centres who had a liver biopsy and LS measurement within 6 months. We included patients with chronic hepatitis C (n = 2,913, 52%), non-alcoholic fatty liver disease (NAFLD, n = 1,073, 19%), alcohol-related liver disease (ALD, n = 946, 17%) or chronic hepatitis B (n = 716, 13%). cACLD was defined as fibrosis stage ≥F3.

RESULTS

Overall, 3,606 (66%) and 987 (18%) patients had LS <10 and >15 kPa, respectively, while cACLD was histologically confirmed in 1,772 (31%) patients. The cut-offs of <10 and >15 kPa showed 75% sensitivity and 96% specificity to exclude and diagnose cACLD, respectively. Examining the ROC curve, a more optimal dual cut-off at <7 and >12 kPa, with 91% sensitivity and 92% specificity for excluding and diagnosing cACLD (AUC 0.87; 95% CI 0.86-0.88; p <0.001) was derived. Specifically, for ALD and NAFLD, a low cut-off of 8 kPa can be used (sensitivity=93%). For the unclassified patients, we derived a risk model based on common patient characteristics with better discrimination than LS alone (AUC 0.74 vs. 0.69; p <0.001).

CONCLUSIONS

Instead of the Baveno VI proposed <10 and >15 kPa dual cut-offs, we found that the <8 kPa (or <7 kPa for viral hepatitis) and >12 kPa dual cut-offs have better diagnostic accuracy in cACLD.

LAY SUMMARY

The term compensated advanced chronic liver disease (cACLD) was introduced in 2015 to describe the spectrum of advanced fibrosis and cirrhosis in asymptomatic patients. It was also suggested that cACLD could be diagnosed or ruled out based on specific liver stiffness values, which can be non-invasively measured by transient elastography. Herein, we assessed the suggested cut-off values and identified alternative values that offered better overall accuracy for diagnosing or ruling out cACLD.

Time-Varying mHAP-III Is the Most Accurate Predictor of Survival in Patients with Hepatocellular Carcinoma Undergoing Transarterial Chemoembolization

INTRODUCTION

The prognosis of patients undergoing transarterial chemoembolization (TACE) is extremely variable, and a confounding factor is that TACE is often repeated several times. We retrospectively evaluated the accuracy of different prognostic scores and staging systems in estimating overall survival (OS) in patients with hepatocellular carcinoma (HCC).

METHODS

An analysis considering prognostic models as time-varying variables was performed, calculating OS from the time of TACE to the time of the subsequent treatment. Total follow-up time for each patient was therefore split into several observation times accounting for each TACE procedure. Values of the likelihood ratio test (LRT) and Akaike information criterion (AIC) were used to compare different systems. Univariable and multivariable analyses were conducted to identify additional factors predictive of OS. We analyzed 1,610 TACE performed in 1,058 patients recorded in the Italian Liver Cancer database from 2008 through 2016.

RESULTS

The median OS of the enrolled patients was 41 months. According to LRT χ² and AIC values based on the time-varying analysis, mHAP-III achieved the best values (41.72 and 4,625.49, respectively, p < 0.0001), indicating the highest predictive performance compared with all other scores (HAP, mHAP-II, ALBI, and pALBI) and staging systems (MELD, ITALICA, CLIP, MESH, MESIAH, JIS, HKLC, and BCLC). In the multivariable Cox proportional hazards model, mHAP-III maintained an independent effect on OS (hazard ratio 1.31, 95% CI: 1.10-1.55, p < 0.0001). Time-varying age, alcoholic etiology, radiologic response to TACE, and performing ablation or surgery after TACE were additional significant variables resulting from the multivariable model.

CONCLUSION

An innovative time-varying analysis revealed that mHAP-III was the most accurate model in predicting OS in patients with HCC undergoing TACE. Other clinical pre- and post-TACE variables were also found to be relevant for this prediction.

Application of LCA modelling in integrated waste management

Life cycle assessment (LCA) has been used in waste management for the last two decades and hundreds of journal papers have been published. The use of LCA in waste management has provided a much-improved holistic view of waste management including waste flows and potential environmental impacts. Although much knowledge has been obtained from LCA studies, there is still a need to use LCA models in integrated waste management. This paper describes six areas where LCA is expected to play a role in waste management in the future: 1) understanding an existing waste management system; 2) improving existing waste management systems; 3) comparing alternative technologies/ technology performance; 4) technology development/prospective technologies; 5) policy development/strategic development; and 6) reporting. Illustrative examples are provided for each application area.

Environmental performances of a modern waste-to-energy unit in the light of the 2019 BREF document

The study compares the environmental performances of a new-generation, large scale, combustion-based waste-to-energy unit, active since 2010, with those of different "virtual" units, defined in the light of the Best Available Techniques REFerence document (BREF) for Waste Incineration published by the European Community on December 2019. The average performances of these units have been evaluated in terms of air emissions, material consumptions and energy recovery, based on data related to 355 "existing" European waste incineration lines and those established for the future "new" plants. An attributional Life Cycle Assessment has been used to compare and quantify the environmental performances of the selected units, all equipped with a moving grate furnace and similar air pollution control systems. A sensitivity analysis quantifies how even more severe requests for emission and energy performances as well as the evolution of the European electricity mix until the year 2030 can affect the comparative assessment. The results indicate that the considered large scale waste-to-energy plant has good environmental performances, even in an electricity mix characterised by 45% of renewable sources. This allows an easy compliance with the Best Available Techniques Associated Emission Levels of the new waste incineration BREF document. Possible further improvements of its performances should be focused mainly on a further increase of the energy efficiency, provided that it is economically viable.

Transjugular intrahepatic portosystemic shunt (TIPS): current indications and strategies to improve the outcomes

Transjugular intrahepatic portosystemic shunt (TIPS) represents a very effective treatment of complications of portal hypertension. Established indications to TIPS in cirrhotic patients include portal hypertensive bleeding and refractory ascites. Over the years additional indications have been proposed, such as the treatment of vascular disease of the liver, hepatic hydrothorax, hepatorenal syndrome and bleeding from ectopic varices. Indications under evaluation include treatment of portal hypertension prior to major abdominal surgery and treatment of portal vein thrombosis. In spite of these advances, there are still uncertainties regarding the appropriate workup for patients to be scheduled for TIPS. Moreover, prevention and management of post-TIPS complications including hepatic encephalopathy and heart failure are still suboptimal. These issues are particularly relevant considering aging in TIPS candidates in Western countries. Correct selection of patients is mandatory to prevent complications which may eventually frustrate the good hemodynamic results and worsen the patient's quality of life or even life expectancy. The possible role of small diameter TIPS to prevent post-procedural complications is discussed.

A review of the valorization and management of industrial spent catalyst waste in the context of sustainable practice: The case of the State of Kuwait in parallel to European industry

Industrial solid waste management encompasses a vital part of developed and developing countries strategies alike. It manages waste generated from vital industries and governs the hazardous waste generated as a major component of integrated waste management strategies. This article reviews the practices that govern the management approaches utilized in the developed world for industrial spent catalysts. It critically assesses the current situation of waste management within the developing world region focusing on the industrial waste component, in a novel attempt to crucially develop a strategy for a way forward based on best practices and future directions with major European industries. The review also draws parallels with European countries to compare their practices with those of the State of Kuwait, which rely solely on landfilling for the management of its industrial waste. Spent catalysts recovery methods are discussed at length covering conventional methods of valuable metals and chemicals recovery (e.g., hydrometallurgical, solid-liquid and liquid-liquid extraction) as well as biological recovery methods. A major gap exists within regulations that govern the practice of managing industrial waste in Kuwait, where it is essential to start regulating industries that generate spent catalysts in-view of encouraging the establishment of valorization industries for metal and chemical recovery. This will also create a sustainable practice within state borders, and can reduce the environmental impact of landfilling such waste in Kuwait.

Biowaste-to-Biomethane: An LCA study on biogas and syngas roads

Biomethane produced from waste-derived biomass (biowaste) is a clean and renewable fuel, which offers substantial reductions of greenhouse gas emissions and resource consumption. Biomethane is currently produced via the "biogas road", which includes the anaerobic digestion of wet biowaste and a successive upgrading of obtained biogas, with good environmental performance. An alternative production strategy is the "syngas road", which includes the gasification of dry or semi-dry biowaste followed by cleaning, conditioning, methanation, and final upgrading of obtained syngas. It is still at a demonstration level but appears of great interest for the highest values of energy efficiency and carbon utilisation. The study acquired technical data from existing plants of both these strategies, and developed a quantitative environmental assessment by means of holistic tools of sustainable engineering: material and substance flow analyses and an attributional life cycle assessment. The technical and environmental performance of the two biomethane roads have been then compared, in terms of energy and process efficiency as well as potential impacts in the main midpoint categories (global warming, respiratory inorganics, and non-renewable energy). The syngas road appears to have higher levels of carbon utilisation and better environmental performance, even though an extended sensitivity analysis shows different results if alternative plant configurations and energy mix are considered. This suggests that R&D studies and policies of economic incentives have to be further implemented for both the analysed strategies, even because they deal with different kind of biowaste, having different availability in different countries.

Life cycle assessment of construction and demolition waste management in a large area of São Paulo State, Brazil

The study evaluated the environmental performance of the construction and demolition waste (C&DW) management in the area of PCJ Watershed, located in the São Paulo State, Brazil, by means of an attributional Life Cycle Assessment. The entire C&DW management under the responsibility of the municipal government was considered. The potential environmental impacts were assessed by using two specific life cycle impact assessment methodologies, CML baseline (v3.03) and Impact 2002+ (v2.12). The results obtained by both methodologies highlighted the importance of the avoided impacts from recovered materials, mainly those related to steel, glass and plastics recycling. In particular, the CML baseline indicated "Human Toxicity" as the most important category, mainly due to the avoided impacts from steel recycling and the generated impacts from transportation in all the C&DW management stages. The Impact 2002+ highlighted instead the role of the categories of "Respiratory Inorganics" and "Global Warming", in accordance with the results related again to steel recycling and transportation but also to landfilling of solid residues. The study considered some alternative scenarios of the mineral fraction management, which quantified the expected advantages of increasing C&DW recycling and improving the quality of recycled aggregates.

An attributional life cycle assessment for an Italian residential multifamily building

The study describes an attributional life cycle assessment carried out according to the ISO standards and focused on an Italian multifamily residential building. The aim was developing an exhaustive and reliable inventory of high-quality primary data, comparing the environmental impacts along the three stages of the building life cycle. The pre-use phase takes into account the production of all the construction materials, transportation, and on-site assembling. The use phase quantifies the resource consumptions for 50 years of the building utilization and ordinary maintenance. The end-of-life phase includes the building demolition and the management of generated wastes. The results quantify how the design criteria affect the environmental performances of the residential building along its life cycle. The role of the pre-use phase appears remarkable for global warming potential (GWP), due to the huge impacts of steel and concrete production processes. The use phase gives the largest contributions, which reach 77% and 84% of the total, for the categories of global warming and non-renewable energy. The end-of-life phase provides limited avoided impacts. A comparative analysis quantifies the improvements achievable with an alternative type of partitions and external walls. Acronyms: AC: air conditioning; C&DW: construction and demolition waste; CFL: compact fluorescent lamp; DHW: domestic hot water; EC: European Commission; EU: European Union; GDP: gross domestic product; GHG: greenhouse gases; GWP: global warming potential; LCA: life cycle assessment; LCI: life cycle inventory; LCIA: life cycle impact assessment; MFA: material flow analysis; NREP: non-renewable energy potential; RINP: respiratory inorganics potential; WFD: Waste Framework Directive.

Interferon-free therapy in hepatitis C virus mixed cryoglobulinaemia: a prospective, controlled, clinical and quality of life analysis

BACKGROUND

Cryoglobulinaemic vasculitis (CV) is a lymphoproliferative disorder related to hepatitis C virus (HCV) infection; anti-viral therapy is the first therapeutic option. CV can be incapacitating, compromising the patients' quality of life (QoL). In a controlled study, interferon-based therapy was associated with a lower virological response in vasculitic patients than in patients without vasculitis. Limited, uncontrolled data on direct-acting anti-virals are available.

AIM

To evaluate safety, clinical efficacy, virological response and the impact of interferon-free treatment on QoL in HCV patients with and without mixed cryoglobulinaemia (MC).

METHODS

We prospectively studied HCV patients with cryoglobulinaemia (with vasculitis-CV- and without vasculitis-MC-) and without cryoglobulinaemia (controls), treated with direct-acting anti-virals. Hepato-virological parameters, CV clinical response and impact on QoL were assessed.

RESULTS

One hundred and eighty-two HCV patients were recruited (85 with CV, 54 with MC and 43 controls). A sustained virological response at 12 weeks (SVR12) was achieved in 166 (91.2%) patients (77/85 CV, 48/54 MC, 41/43 controls). In CV SVR patients, cryocrit levels progressively decreased and clinical response progressively improved, reaching 96.7%, 24 weeks after treatment. QoL, baseline physical and mental component summaries were lower in the CV group compared to the other groups (P < 0.05). Scores improved in all groups, and significantly in CV patients after SVR.

CONCLUSIONS

No significant differences in SVR rates were recorded between cryoglobulinaemic patients and controls and a high clinical and immunological efficacy was confirmed in CV, supporting the role of interferon-free therapy as the first therapeutic option. Interestingly, CV patients had worse baseline QoL than other HCV-positive groups and interferon-free therapy was effective in significantly increasing QoL, suggesting the important role of direct-acting anti-viral-based therapy in improving CV's individual and social burden.

Reforming sewage sludge pyrolysis volatile with Fe-embedded char: Minimization of liquid product yield

Obtaining high quality syngas from sewage sludge (SS) means transferring a low-grade SS into a high-grade fuel or raw materials for chemical products. In this study, Fe is added to SS in form of Fe₂(SO₄)₃ to produce an effective and self-sufficient catalyst in order to obtain more syngas and minimize liquid products from SS pyrolysis. The Fe-embedded sewage sludge chars (SSCs) were used as catalysts for volatile reforming at 600°C. It has been found that the gas yield increases from 15.9 to 35.8wt% of the SS and that of liquids decreases from 31.9 to 10.2wt% after volatile reforming with Fe-embedded SSC when Fe was added equal to 7 % in the dried SS. In addition, the content of nitrogen-containing compounds in the oily products decreased. After reforming with Fe-embedded SSC, the molar fractions of syngas combustible components, including H₂, CH₄ and CO, increase, and the higher heating value of the syngas increased to 17.0MJ/Nm³ from the original 12.5MJ/Nm³ obtained from SS pyrolysis at 550°C. Moreover, the volatile reforming seems to reduce the level of some important syngas pollutants, like H₂S, HCl and HCN, even though it was also observed an increase of the contents of SO₂, NH₃, NO_2, HCNO and N₂O.

Environmental performances of different configurations of a material recovery facility in a life cycle perspective

The study evaluated the environmental performances of an integrated material recovery facility (MRF) able to treat 32kt/y of unsorted mixed waste, made of residuals from household source separation and separate collection. The facility includes a mechanical sorting platform for the production of a solid recovered fuel (SRF) utilized in an external waste-to-energy plant, bio-cells for tunnel composting of organic fraction, and a sanitary landfill for the safe disposal of ultimate waste. All the MRF sub-units have been analysed in depth in order to acquire reliable data for a life cycle assessment study, focused on the environmental performances of different configurations of the facility. The study investigated a "past" configuration, including just mechanical sorting, landfilling and biogas combustion in a gas engine, and the "present" one, which includes also a composting unit. Two possible "future" configurations, having a gasifier inside the MRF battery limits, have been also analysed, assessing the performances of two fluidized bed reactors of different size, able to gasify only the residues generated by the sorting platform or the whole amount of produced SRF, respectively. The analysis evaluated the contributions of each unit in the different configurations and allowed a reliable assessment of the technological evolution of the facility. The results quantified the positive effect of the inclusion of an aerobic treatment of the waste organic fraction. The SRF gasification in situ appears to improve the MRF environmental performances in all the impact categories, with the exclusion of that of global warming.

Validity criteria for the diagnosis of fatty liver by M probe-based controlled attenuation parameter

BACKGROUND & AIMS

Controlled attenuation parameter (CAP) can be performed together with liver stiffness measurement (LSM) by transient elastography (TE) and is often used to diagnose fatty liver. We aimed to define the validity criteria of CAP.

METHODS

CAP was measured by the M probe prior to liver biopsy in 754 consecutive patients with different liver diseases at three centers in Europe and Hong Kong (derivation cohort, n=340; validation cohort, n=414; 101 chronic hepatitis B, 154 chronic hepatitis C, 349 non-alcoholic fatty liver disease, 37 autoimmune hepatitis, 49 cholestatic liver disease, 64 others; 277 F3-4; age 52±14; body mass index 27.2±5.3kg/m²). The primary outcome was the diagnosis of fatty liver, defined as steatosis involving ≥5% of hepatocytes.

RESULTS

The area under the receiver-operating characteristics curve (AUROC) for CAP diagnosis of fatty liver was 0.85 (95% CI 0.82-0.88). The interquartile range (IQR) of CAP had a negative correlation with CAP (r=-0.32, p<0.001), suggesting the IQR-to-median ratio of CAP would be an inappropriate validity parameter. In the derivation cohort, the IQR of CAP was associated with the accuracy of CAP (AUROC 0.86, 0.89 and 0.76 in patients with IQR of CAP <20 [15% of patients], 20-39 [51%], and ≥40dB/m [33%], respectively). Likewise, the AUROC of CAP in the validation cohort was 0.90 and 0.77 in patients with IQR of CAP <40 and ≥40dB/m, respectively (p=0.004). The accuracy of CAP in detecting grade 2 and 3 steatosis was lower among patients with body mass index ≥30kg/m² and F3-4 fibrosis.

CONCLUSIONS

The validity of CAP for the diagnosis of fatty liver is lower if the IQR of CAP is ≥40dB/m. Lay summary: Controlled attenuation parameter (CAP) is measured by transient elastography (TE) for the detection of fatty liver. In this large study, using liver biopsy as a reference, we show that the variability of CAP measurements based on its interquartile range can reflect the accuracy of fatty liver diagnosis. In contrast, other clinical factors such as adiposity and liver enzyme levels do not affect the performance of CAP.

Serial combination of non-invasive tools improves the diagnostic accuracy of severe liver fibrosis in patients with NAFLD

BACKGROUND

The accuracy of available non-invasive tools for staging severe fibrosis in patients with nonalcoholic fatty liver disease (NAFLD) is still limited.

AIM

To assess the diagnostic performance of paired or serial combination of non-invasive tools in NAFLD patients.

METHODS

We analysed data from 741 patients with a histological diagnosis of NAFLD. The GGT/PLT, APRI, AST/ALT, BARD, FIB-4, and NAFLD Fibrosis Score (NFS) scores were calculated according to published algorithms. Liver stiffness measurement (LSM) was performed by FibroScan.

RESULTS

LSM, NFS and FIB-4 were the best non-invasive tools for staging F3-F4 fibrosis (AUC 0.863, 0.774, and 0.792, respectively), with LSM having the highest sensitivity (90%), and the highest NPV (94%), and NFS and FIB-4 the highest specificity (97% and 93%, respectively), and the highest PPV (73% and 79%, respectively). The paired combination of LSM or NFS with FIB-4 strongly reduced the likelihood of wrongly classified patients (ranging from 2.7% to 2.6%), at the price of a high uncertainty area (ranging from 54.1% to 58.2%), and of a low overall accuracy (ranging from 43% to 39.1%). The serial combination with the second test used in patients in the grey area of the first test and in those with high LSM values (>9.6 KPa) or low NFS or FIB-4 values (<-1.455 and <1.30, respectively) overall increased the diagnostic performance generating an accuracy ranging from 69.8% to 70.1%, an uncertainty area ranging from 18.9% to 20.4% and a rate of wrong classification ranging from 9.2% to 11.3%.

CONCLUSION

The serial combination of LSM with FIB-4/NFS has a good diagnostic accuracy for the non-invasive diagnosis of severe fibrosis in NAFLD.

Non-invasive assessment of liver fibrosis in patients with HBV-related chronic liver disease undergoing antiviral treatment: A preliminary study

In chronic hepatitis B (CHB) patients, fibrosis assessment during antiviral treatment is a key step in the clinical management. Aim of this study was to evaluate the performance of elastography in assessing fibrosis stage in CHB before and after two years of nucleoside/nucleotide analogues (NUC) treatment in comparison with indirect serum markers. CHB diagnosis was made according to standard criteria. A clinical and virological evaluation was performed at baseline and again at 3, 6, 9, 12 18, and 24 months during treatment. Fibrosis was evaluated by liver biopsy, elastography and indirect serum markers. Of 75 patients, 50 had CHB, HBeAg negative and were deemed eligible for this study. Of these, 22 underwent liver biopsy. Mean histo-morphometric values of fibrotic tissue differed significantly in the stage < S3 vs. stage ≥S3: 2.01±2.62% vs. 12.85±7.31% (p=0.03), respectively. At 18 and 24 months, stiffness values were statistically reduced from those previously observed (P=0.03 and P<0.001). At 24 months the values of APRI, FIB-4 and LOK were not different from baseline values, while the value of FORNS score at 24 months was the only one statistically reduced. In two patients with fibrosis stage S3 and S6, respectively, fibrosis regressed to stage S2 and S5. In conclusion, the results of the present study show that liver histology, stiffness and FORNS score improve significantly during a long-term follow-up of HBV patients successfully treated with NUC. These results strongly suggest that the non-invasive evaluation of liver fibrosis represents a key step in the management and treatment of chronic HBV hepatitis.

Improved noninvasive prediction of liver fibrosis by liver stiffness measurement in patients with nonalcoholic fatty liver disease accounting for controlled attenuation parameter values

Liver stiffness measurement (LSM) frequently overestimates the severity of liver fibrosis in nonalcoholic fatty liver disease (NAFLD). Controlled attenuation parameter (CAP) is a new parameter provided by the same machine used for LSM and associated with both steatosis and body mass index, the two factors mostly affecting LSM performance in NAFLD. We aimed to determine whether prediction of liver fibrosis by LSM in NAFLD patients is affected by CAP values. Patients (n = 324) were assessed by clinical and histological (Kleiner score) features. LSM and CAP were performed using the M probe. CAP values were grouped by tertiles (lower 132-298, middle 299-338, higher 339-400 dB/m). Among patients with F0-F2 fibrosis, mean LSM values, expressed in kilopascals, increased according to CAP tertiles (6.8 versus 8.6 versus 9.4, P = 0.001), and along this line the area under the curve of LSM for the diagnosis of F3-F4 fibrosis was progressively reduced from lower to middle and further to higher CAP tertiles (0.915, 0.848-0.982; 0.830, 0.753-0.908; 0.806, 0.723-0.890). As a consequence, in subjects with F0-F2 fibrosis, the rates of false-positive LSM results for F3-F4 fibrosis increased according to CAP tertiles (7.2% in lower versus 16.6% in middle versus 18.1% in higher). Consistent with this, a decisional flowchart for predicting fibrosis was suggested by combining both LSM and CAP values.

CONCLUSIONS

In patients with NAFLD, CAP values should always be taken into account in order to avoid overestimations of liver fibrosis assessed by transient elastography. (Hepatology 2017;65:1145-1155).

Life cycle assessment of the end-of-life phase of a residential building

The study investigates the potential environmental impacts related to the end-of-life phase of a residential building, identified in a multifamily dwelling of three levels, constructed in the South of Italy by utilizing conventional materials and up-to-date procedures. An attributional life cycle assessment has been utilised to quantify the contributions of each stage of the end-of-life phase, with a particular attention to the management of the demolition waste. The investigation takes into account the selective demolition, preliminary sorting and collection of main components of the building, together with the processes of sorting, recycling and/or disposal of main fractions of the demolition waste. It quantifies the connections between these on-site and off-site processes as well as the main streams of materials sent to recycling, energy recovery, and final disposal. A sensitivity analysis has been eventually carried out by comparing the overall environmental performances of some alternative scenarios, characterised by different criteria for the demolition of the reference building, management of demolition waste and assessment of avoided burdens of the main recycled materials. The results quantify the advantage of an appropriate technique of selective demolition, which could increase the quality and quantity of residues sent to the treatment of resource recovery and safe disposal. They also highlight the contributions to the positive or negative environmental impact of each stage of the investigated waste management system. The recycling of reinforcing steel appears to play a paramount role, accounting for 65% of the total avoided impacts related to respiratory inorganics, 89% of those for global warming and 73% of those for mineral extraction.

Safety and efficacy of ruxolitinib in splanchnic vein thrombosis associated with myeloproliferative neoplasms

Splanchnic vein thrombosis (SVT) is one of the vascular complications of myeloproliferative neoplasms (MPN). We designed a phase 2 clinical trial to evaluate safety and efficacy of ruxolitinib in reducing splenomegaly and improving disease-related symptoms in patients with MPN-associated SVT. Patients diagnosed with myelofibrosis (12 cases), polycythemia vera (5 cases) and essential thrombocythemia (4 cases) received ruxolitinib for 24 weeks in the core study period. Spleen volume was assessed by magnetic resonance imaging (MRI) and splanchnic vein circulation by echo-Doppler analysis. Nineteen patients carried JAK2V617F, one had MPLW515L, and one CALRL367fs*46 mutation. Eighteen patients had spleno-portal-mesenteric thrombosis, two had Budd-Chiari syndrome, and one had both sites involved; 16 patients had esophageal varices. Ruxolitinib was well tolerated with hematological toxicities consistent with those of patients without SVT and no hemorrhagic adverse events were recorded. After 24 weeks of treatment, spleen volume reduction ≥35% by MRI was achieved by 6/21 (29%) patients, and a ≥50% spleen length reduction by palpation at any time up to week 24 was obtained by 13/21 (62%) patients. At week 72, 8 of the 13 (62%) patients maintained the spleen response by palpation. No significant effect of treatment on esophageal varices or in splanchnic circulation was observed. MPN-related symptoms, evaluated by MPN-symptom assessment form (SAF) TSS questionnaire, improved significantly during the first 4 weeks and remained stable up to week 24. In conclusion, this trial shows that ruxolitinib is safe in patients with MPN-associated SVT, and effective in reducing spleen size and disease-related symptoms.

The metabolic syndrome and chronic liver disease

The prevalence of the metabolic syndrome (MetS), a cluster of cardiovascular risk factors associated with obesity and insulin resistance, is dramatically increasing in Western and developing countries. This disorder is not only associated with a higher risk of appearance of type 2 diabetes and cardiovascular events, but impacts on the liver in different ways. Nonalcoholic fatty liver disease (NAFLD) is considered the hepatic manifestation of MetS, and is characterized by triglyceride accumulation and a variable degree of hepatic injury, inflammation, and repair. In the presence of significant hepatocellular injury and inflammation, the picture is defined 'nonalcoholic steatohepatitis' (NASH), that has the potential to progress to advanced fibrosis and cirrhosis. Diagnosis of NASH is based on a liver biopsy, and active search for noninvasive tests is ongoing. Progression of steatohepatitis to advanced fibrosis or cirrhosis has been shown in at least one third of patients followed with paired biopsies. Presence of NASH is associated with lower life expectancy, both due to liver-related death and to an increase in cardiovascular events. The appearance of NAFLD is mainly dependent on increased flow of fatty acids derived from an excess of lipolysis from insulin-resistant adipose tissue. Development of NASH is based on lipotoxicity and is influenced by signals derived from outside the liver and from intrahepatic activation of inflammatory and fibrogenic pathways. The presence of the MetS is also associated with worse outcomes in patients with cirrhosis due to any causes, and has complex interactions with hepatitis C virus infection. Moreover, MetS poses a higher risk of development of hepatocellular carcinoma, not necessarily through the development of NASH-related cirrhosis. In conclusion, the presence of metabolic alterations has a severe and multifaceted impact on the liver, and is responsible for a higher risk of liver-dependent and -independent mortality.

Fluidized bed gasification of industrial solid recovered fuels

The study evaluates the technical feasibility of the fluidized bed gasification of three solid recovered fuels (SRFs), obtained as co-products of a recycling process. The SRFs were pelletized and fed to a pilot scale bubbling fluidized bed reactor, operated in gasification and co-gasification mode. The tests were carried out under conditions of thermal and chemical steady state, with a bed of olivine particles and at different values of equivalence ratio. The results provide a complete syngas characterization, in terms of its heating value and composition (including tars, particulates, and acid/basic pollutants) and of the chemical and physical characterization of bed material and entrained fines collected at the cyclone outlet. The feasibility of the fluidized bed gasification process of the different SRFs was evaluated with the support of a material and substance flow analysis, and a feedstock energy analysis. The results confirm the flexibility of fluidized bed reactor, which makes it one of the preferable technologies for the gasification of different kind of wastes, even in co-gasification mode. The fluidized bed gasification process of the tested SRFs appears technically feasible, yielding a syngas of valuable quality for energy applications in an appropriate plant configuration.

Hepatocellular carcinoma: Where are we?

Hepatocellular carcinoma (HCC) is the second cause of death due to malignancy in the world, following lung cancer. The geographic distribution of this disease accompanies its principal risk factors: Chronic hepatitis B virus and hepatitis C virus infection, alcoholism, aflatoxin B1 intoxication, liver cirrhosis, and some genetic attributes. Recently, type II diabetes has been shown to be a risk factor for HCC together with obesity and metabolic syndrome. Although the risk factors are quite well known and it is possible to diagnose HCC when the tumor is less than 1 cm diameter, it remains elusive at the beginning and treatment is often unsuccessful. Liver transplantation is thus far considered the best treatment for HCC as it cures HCC and the underlying liver disease. Using the Milan criteria, overall survival after liver transplantation for HCC is about 70% after 5 years. Many attempts have been made to go beyond the Milan Criteria and according to recent works reasonably good results have been achieved by using a histochemical marker such as cytokeratine 19 and the so-called "up to seven criteria" to divide patients into categories according to their risk of relapse. In addition to liver transplantation other therapies have been proposed such as resection, tumor ablation by different means, embolization and chemotherapy. An important step in the treatment of advanced HCC has been the introduction of sorafenib, the first oral, systemic drug that has provided significant improvement in survival. Treatment of HCC patients must be multidisciplinary and by using the different approaches discussed in this review it is possible to offer prolonged survival and quite good and sometimes even excellent quality of life to many patients.

Paradoxical embolization in TIPS: take a closer look to the heart

No definitive indications are provided in the literature for pre-TIPS patient workup, which is often limited to prevent the incidence of refractory hepatic encephalopathy or unacceptable deterioration of liver function. Concerning cardiologic workup, efforts are generally limited at excluding ventricular failure or porto pulmonary hypertension. The cases presented herein focus the attention of the readers on the possible occurrence of post-TIPS paradoxical embolization in the presence of a patent foramen ovale, frequently recognized in adult population. In conclusion, although this complication has been already reported in literature, in the present manuscript we concentrate on possible additional risk factors which may allow to identify a subset of patients with a higher likelihood to experience paradoxical embolization following TIPS. Another important line of information presented herein is the feasibility of percutaneous closure of a patent foramen ovale before TIPS deployment in the presence of portal vein thrombosis and possibly with additional risk factors.

A life cycle assessment of environmental performances of two combustion- and gasification-based waste-to-energy technologies

An attributional life cycle analysis (LCA) was developed to compare the environmental performances of two waste-to-energy (WtE) units, which utilize the predominant technologies among those available for combustion and gasification processes: a moving grate combustor and a vertical shaft gasifier coupled with direct melting. The two units were assumed to be fed with the same unsorted residual municipal waste, having a composition estimated as a European average. Data from several plants in operation were processed by means of mass and energy balances, and on the basis of the flows and stocks of materials and elements inside and throughout the two units, as provided by a specific substance flow analysis. The potential life cycle environmental impacts related to the operations of the two WtE units were estimated by means of the Impact 2002+ methodology. They indicate that both the technologies have sustainable environmental performances, but those of the moving grate combustion unit are better for most of the selected impact categories. The analysis of the contributions from all the stages of each specific technology suggests where improvements in technological solutions and management criteria should be focused to obtain further and remarkable environmental improvements.

Long-term effect of HCV eradication in patients with mixed cryoglobulinemia: a prospective, controlled, open-label, cohort study

Limited data are available about the efficacy of antiviral treatment in hepatitis C virus (HCV)-associated mixed cryoglobulinemia (MC), especially concerning the long-term effects of HCV eradication. The aim of this study was to evaluate the influence of MC on the virological response and the long-term effects of viral eradication on MC. We prospectively enrolled 424 HCV(+) patients belonging to the following groups: MC syndrome (MCS)-HCV (121 patients with symptomatic MC), MC-HCV (132 patients with asymptomatic MC), and HCV (158 patients without MC). Pegylated interferon plus ribavirin treatment was administered according to standard protocols. Posttreatment follow-up ranged from 35 to 124 months (mean 92.5 months). A significant difference was observed in the rate of sustained virological response between the HCV group and both the MC-HCV (P = 0.009) and MC-HCV+MCS-HCV (P = 0.014) groups. Multivariate logistic regression analysis identified cryoglobulinemia as an independent prognostic factor of nonresponse. The clinical-immunological response in MCS-HCV correlated with the virological one. All patients with sustained virological response also experienced a sustained clinical response, either complete or partial. In the majority of sustained virological response patients all MCS symptoms persistently disappeared (36 patients, 57%); in only two (3%) did definite MCS persist. All virological nonresponders were also clinical nonresponders, in spite of a transient improvement in some cases. No evolution to lymphoma was observed. For the first time we have evaluated both the effects of interferon-based therapy on HCV patients with and without MC and with and without symptoms, as well as the long-term effects of viral eradication on MC.

CONCLUSION

MC is a negative prognostic factor of virological response. Clearance of HCV led to persistent resolution or improvement of MCS, strongly suggesting the need for a next generation of highly effective antiviral drugs.

Evaluation of the prognostic value of liver stiffness in patients with hepatitis C virus treated with triple or dual antiviral therapy: A prospective pilot study

AIM: To evaluate the association between liver stiffness (LS) prior to the initiation of dual/triple therapy and viral response.

METHODS: LS was measured in all patients before treatment was administered. The therapeutic approach was based on hepatic, virological, and immunological evaluations and considered the fact that patients with severe fibrosis (F3) or compensated cirrhosis (F4) in Child-Pugh class A are the primary candidates for triple therapy. In total, 65 hepatitis C virus (HCV) patients were treated with Peg-interferon/ribavirin (Peg-IFN/RBV); 24 patients were classified as genotypes 1/4 (36.92%), and 41 patients were classified as genotypes 2/3 (63.08%) (dual therapy). In addition, 20 HCV treatment-experienced genotype 1 patients were treated with PegIFN-RBV and boceprevir (triple therapy). Wilcoxon rank-sum tests were used to compare the groups.

RESULTS: LS significantly differed between dual therapy and triple therapy (P = 0.002). The mean LS value before dual therapy treatment was 8.61 ± 5.79 kPa and was significantly different between patients achieving a sustained virologic response (SVR) 24 weeks after therapy and those who did not (7.23 ± 5.18 kPa vs 11.72 ± 5.99 kPa, respectively, P = 0.0003). The relative risk of non-response to therapy was 4.45 (95%CI: 2.32-8.55). The attributable risk of non-response to therapy was 49%. The mean LS value before triple therapy treatment was 13.29 ± 8.57 kPa and was significantly different between patients achieving and not achieving SVR24 (9.41 ± 5.05 vs 19.11 ± 9.74, respectively; P = 0.008). The relative risk of non-response to therapy was 5.57% (95%CI: 1.50-20.65). The attributable risk of non-response to therapy (70%) was increased compared with dual therapy patients. Pre-treatment stiffness > 12 kPa was significantly associated with non-SVR (P < 0.025) in both groups.

CONCLUSION: Pre-treatment liver stiffness may be useful for predicting the response to treatment in patients treated with either dual or triple anti-HCV therapy.

The effect of ash composition on gasification of poultry wastes in a fluidized bed reactor

The effect of ash composition on the fluidized bed gasification behaviour of poultry wastes was investigated by operating a pre-pilot scale reactor with two batches of manure obtained from an industrial chicken farm. The experimental runs were carried out by keeping the fluidized bed velocity fixed (at 0.4m s(-1)) and by varying the equivalence ratio between 0.27 and 0.40, so obtaining bed temperature values between 700 and 800 °C. The performance of the gasification process was assessed by means of mass balances as well as material and feedstock energy analyses, and reported in terms of cold gas efficiency (CGE), specific energy production, low heating value of obtained syngas and yield of undesired by-products. The experimental results indicate the crucial role of ash amount and composition of the two poultry wastes. In particular, higher ash content (25.1% instead of 17.2%) and higher fractions of calcium, phosphorous and potassium (with an increase of 24, 30 and 28%, respectively) induce a dramatic reduction of all the process performance parameters: CGE reduces from 0.63 to 0.33 and the specific energy from 2.1 to 1.1 kWh kg(fuel)(-1). At the same time, the formation of alkali compounds and their behaviour inside the fluidized bed reactor determine an increase of feedstock energy losses, which is related to occurrence of sintering and bridging between bed particles.

Assessment of liver stiffness in patients with HCV and mixed cryoglobulinemia undergoing rituximab treatment

INTRODUCTION

Mixed cryoglobulinemia (MC) is a HCV-related lymphoproliferative disorder generally associated with advanced liver disease. Liver stiffness has been significantly correlated with histopathological stage of fibrosis. Moreover, it was influenced by necroinflammatory activity. Rituximab (RTX) is a chimeric anti-CD20 monoclonal antibody inducing transient B lymphocytes depletion that was shown to be useful and safe in the majority of HCV MC patients, leading also to improvement of cirrhotic syndrome. Aim of this study was to evaluate the modifications of liver stiffness following RTX treatment in HCV-related MC patients.

MATERIALS AND METHODS

Fourteen consecutive patients (10 F, 4 M; mean age 60.43 ± 43) with HCV-related chronic hepatitis (n = 10) or cirrhosis (n = 4) and MC, eligible for RTX treatment, were prospectively enrolled. Intravenous injection of 1 g of RTX was performed at day 0 and at day 15. Assessment of stiffness was carried out by Fibroscan (Echosens, Paris-France) at baseline, 15 days after the first infusion, and at month 1, 3 and 6 after therapy.

RESULTS

MC symptoms significantly improved during the study, especially during the first 3 months. Liver stiffness observed 3 months after treatment was significantly reduced when compared with pre-treatment values (p = 0.01). This difference disappeared after 6 months of follow-up. Cytofluorimetric analysis showed a decrease of CD19+ peripheral blood cells, with the nadir at month 3 after therapy and B cell compartment reconstitution after 6 months.

CONCLUSION

This study, for the first time showed that RTX-treatment in HCV-related MC induces a reduction of liver stiffness that is strictly associated with the B-cell depletion.

Predictors of survival in patients with established cirrhosis and hepatocellular carcinoma treated with sorafenib

AIM: To investigate in greater detail the efficacy and safety of sorafenib for the treatment of hepatocellular carcinoma (HCC) in patients with established cirrhosis.

METHODS: From October 2009 to July 2012 patients with an established diagnosis of cirrhosis and HCC treated with sorafenib were consecutively enrolled. According to the Barcelona Clinic Liver Cancer (BCLC) classification, patients were in the advanced stage (BCLC-C) or in the intermediate stage (BCLC-B) but unfit or unresponsive to other therapeutic strategies. Treatment was evaluated performing a 4-phase computed tomography or magnetic resonance imaging scan every 2-3 mo, and analyzed according to the modified Response Evaluation Criteria in Solid Tumors. Sorafenib was administered at 800 mg/d, until radiological progression or occurrence of unacceptable adverse events (AEs). Univariate and multivariate analyses identified predictors of 16-wk clinical benefit and overall survival.

RESULTS: Forty-four patients were enrolled, 15 had intermediate HCC and 14 a Child-Pugh score of B7. AEs caused treatment interruption in 19 patients (43%), and median treatment duration was shorter in this subset (5 wk vs 19 wk, P < 0.001) and in the BCLC-C subgroup (13 wk vs 40 wk, P = 0.015). No significant differences in the reason for treatment interruption or in treatment duration were found comparing patients in Child-Pugh class A vs B or in patients older or younger than 70 years. After 16 wk of treatment, 18 patients (41%) had stable disease or partial response. Patients with viral infection or BCLC-C were at higher risk of disease progression. ECOG, extrahepatic spread, macrovascular invasion, alpha-fetoprotein or alkaline phosphatase levels at admission were independent predictors of overall survival.

CONCLUSION: In patients with cirrhosis and HCC treated with sorafenib, AEs are a common cause of early treatment withdrawal. Vascular invasion and extrahepatic spread condition early response to treatment and survival. Baseline biochemical parameters may be helpful to identify patients at higher risk of shorter overall survival.

Longitudinal assessment of liver stiffness in patients undergoing antiviral treatment for hepatitis C

BACKGROUND

Liver stiffness has been suggested as a parameter of fibrosis progression/regression in hepatitis C virus (HCV) patients.

AIM

To evaluate stiffness before and after peginterferon-ribavirin treatment.

METHODS

Stiffness was prospectively measured in 74 HCV patients, 32 genotypes 1/4 (43.25%) and 42 genotypes 2/3 (56.75%), before, at end of treatment, and after 3 years of follow-up (49 patients). On the same study day, 21 patients underwent liver biopsy.

RESULTS

In 55 patients with sustained virological response (74.32%), liver stiffness decreased significantly at end of therapy (6.8±4.9kPa) vs. baseline (9.5±6.9kPa, p=0.04). The decrease vs. baseline was maintained in 30 sustained virological response patients after 3 years follow-up (6.8±4.6kPa vs. 10.8±8.5kPa, p=0.0141). No difference was found at end of treatment vs. baseline (10.1±4.7kPa vs. 9.7±4.2kPa, p=0.825) and after 3 years of follow-up vs. baseline (10.2±3.4kPa vs. 9.7±4.2kPa, p=0.765) in null responders. Similar results were found in relapsers at end of treatment vs. baseline (13.7±7.7kPa vs. 15.2±8.2kPa, p=0.74), and after 3 years of follow-up vs. baseline (16.9±10.0kPa vs. 15.2±8.2kPa, p=0.734). Pre-treatment stiffness >12kPa was significantly associated with no SVR (p<0.025), RR=2.44 (95%C.I. 1.17-5.07).

CONCLUSION

Liver stiffness may be useful to assess long-term antiviral treatment response.

Liver stiffness is influenced by a standardized meal in patients with chronic hepatitis C virus at different stages of fibrotic evolution

Transient elastography (TE) is increasingly employed in clinical practice for the noninvasive detection of tissue fibrosis in patients with chronic liver disease (CLD), and particularly chronic hepatitis C virus (HCV)-related hepatitis. The present study was designed to provide a definitive characterization of the "confounding" increase in liver stiffness (LS) following a standardized meal in a consecutive population of 125 patients with chronic HCV infection at different stages of fibrotic evolution. LS values were obtained after overnight fasting and 15, 30, 45, 60, and 120 minutes following the onset of a standardized liquid meal (400 mL, 600 Kcal, 16.7% protein, 53.8% carbohydrates, 29.5% fat). An evident increase in LS values was observed 15 to 45 minutes after the onset of the meal with return to baseline premeal levels within 120 minutes in all patients. The peak postmeal delta increase in LS was progressively more marked with increasing stages of fibrosis (P < 0.001), becoming maximal in patients with cirrhosis. However, the probability of identifying the Metavir stage of fibrosis, the Child-Pugh class, or the presence/absence of esophageal varices with the postmeal delta increase in LS was inferior to that obtained with baseline LS values.

CONCLUSION

The results of the present study provide definitive evidence of the confounding effect of a meal on the accuracy of LS measurements for the prediction of fibrosis stage in patients with chronic HCV hepatitis and suggest that a fasting period of 120 minutes should be observed before the performance of TE.

Element partitioning in combustion- and gasification-based waste-to-energy units

A critical comparison between combustion- and gasification-based waste-to-energy systems needs a deep knowledge of the mass flows of materials and elements inside and throughout the units. The study collected and processed data from several moving grate conventional incinerators and high-temperature shaft gasifiers with direct melting, which are in operation worldwide. A material and substance flow analysis was then developed to systematically assess the flows and stocks of materials and elements within each waste-to-energy unit, by connecting the sources, pathways, and intermediate and final sinks of each species. The patterns of key elements, such as carbon, chloride and heavy metals, in the different solid and gaseous output streams of the two compared processes have been then defined. The combination of partitioning coefficients with the mass balances on atomic species and results of mineralogical characterization from recent literatures was used to estimate a composition of bottom ashes and slags from the two types of waste-to-energy technologies. The results also allow to quantify some of the performance parameters of the units and, in particular, the potential reduction of the amount of solid residues to be sent to final disposal.

Elastography, spleen size, and platelet count identify portal hypertension in patients with compensated cirrhosis

BACKGROUND & AIMS

Noninvasive methods are needed to identify clinically significant portal hypertension (CSPH) and esophageal varices (EVs) in patients with compensated cirrhosis. We looked for markers of the presence of CSPH and EVs in patients with cirrhosis.

METHODS

We performed a cross-sectional study that included a training set of 117 patients with compensated cirrhosis, confirmed by histology, from a tertiary referral center. Spleen diameter was measured by ultrasound, and liver stiffness (LS) was measured by transient elastography; endoscopy was used as the standard for detection of EVs, and measurements of hepatic venous pressure gradient were used as the standard for identifying CSPH. We assessed the ability of platelet count, spleen diameter, LS, and combinations of these factors (ie, ratio of platelet count to spleen size, and LS × spleen size/platelet count [LSPS]) to identify patients with CSPH and EV. The analysis included 2 new statistical models: the PH risk score and the varices risk score. Results were validated using an independent series of 56 patients with compensated patients from another center.

RESULTS

LS was the best single noninvasive variable for identifying patients with CSPH (area under the receiver operating characteristic, 0.883; 95% confidence interval [CI], 0.824-0.943; P < .0001). The area under the receiver operating characteristic value increased when LS was combined with platelet count and spleen size, either as LSPS (0.918; 95% CI, 0.872-0.965; P < .0001) or PH risk score (0.935; 95% CI, 0.893-0.977; P < .0001). More than 80% of patients were accurately classified using LSPS and PH risk score. Analyses of the varices risk score and LSPS were superior to all other noninvasive tests for identifying patients with EVs (area under the receiver operating characteristic, 0.909; 95% CI, 0.841-0.954 and 0.882; 95% CI, 0.810-0.935, respectively); they correctly classified 85% of patients in the training set and 75% in the validation set.

CONCLUSIONS

Combined data on LS, spleen diameter, and platelet count can be used to identify patients with compensated cirrhosis most likely to have CSPH and EV.

Measurement of spleen stiffness to evaluate portal hypertension and the presence of esophageal varices in patients with HCV-related cirrhosis

BACKGROUND & AIMS

The hepatic vein pressure gradient (HVPG) is the standard used to determine the degree of portal hypertension (PH) and an important prognostic factor for patients with cirrhosis; HVPG values correlate with the presence of esophageal varices (EV). However, HVPG can only be accurately determined at specialized centers; noninvasive methods are needed to predict HVPG values and the presence of EV. We compared the diagnostic performance of spleen stiffness (SS) measurement by transient elastography with that of liver stiffness (LS) and of other recently proposed noninvasive tests.

METHODS

We measured SS and LS in 100 consecutive patients with hepatitis C virus-induced cirrhosis. Patients were also assessed by FibroScan, HVPG, esophagogastroduodenoscopy, and liver biopsy. We also analyzed LS-spleen diameter to platelet ratio score and platelet count to spleen diameter.

RESULTS

SS and LS were more accurate than other noninvasive parameters in identifying patients with EV and different degrees of PH. A linear model that included SS and LS accurately predicted HVPG values (R(2) = 0.85). The results were internally validated using bootstrap analysis.

CONCLUSIONS

Measurement of SS can be used for noninvasive assessment and monitoring of PH and to detect EV in patients with hepatitis C virus-induced cirrhosis.

Process and technological aspects of municipal solid waste gasification. A review

The paper proposes a critical assessment of municipal solid waste gasification today, starting from basic aspects of the process (process types and steps, operating and performance parameters) and arriving to a comparative analysis of the reactors (fixed bed, fluidized bed, entrained bed, vertical shaft, moving grate furnace, rotary kiln, plasma reactor) as well as of the possible plant configurations (heat gasifier and power gasifier) and the environmental performances of the main commercially available gasifiers for municipal solid wastes. The analysis indicates that gasification is a technically viable option for the solid waste conversion, including residual waste from separate collection of municipal solid waste. It is able to meet existing emission limits and can have a remarkable effect on reduction of landfill disposal option.

The O₂-enriched air gasification of coal, plastics and wood in a fluidized bed reactor

The effect of oxygen-enriched air during fluidized bed co-gasification of a mixture of coal, plastics and wood has been investigated. The main components of the obtained syngas were measured by means of on-line analyzers and a gas chromatograph while those of the condensate phase were off-line analysed by means of a gas chromatography-mass spectrometer (GC-MS). The characterization of condensate phase as well as that of the water used as scrubbing medium completed the performed diagnostics. The experimental results were further elaborated in order to provide material and substances flow analyses inside the plant boundaries. These analyses allowed to obtain the main substance distribution between solid, gaseous and condensate phases and to estimate the conversion efficiency of carbon and hydrogen but also to easily visualise the waste streams produced by the process. The process performance was then evaluated on the basis of parameters related to the conversion efficiency of fuels into valuable products (i.e. by considering tar and particulate as process losses) as well as those related to the energy recovery.