How does plastic compare with alternative materials in the packaging sector? A systematic review of LCA studies.

In the recent years, packaging made of conventional plastics has been increasingly replaced by materials believed to be more sustainable. However, perceived sustainability must align with scientific assessments, such as life cycle assessments (LCAs). This review analysed 53 peer-reviewed studies published in the time range 2019-2023, aiming at understanding the state of the art in LCA about the environmental impacts of packaging by focusing on the comparison between plastics and alternative materials. The literature showed that consumer perceptions often differ from LCA findings and revealed that, frequently, conventional plastics are not the least environmentally friendly choice. Bioplastics typically show benefits only in the climate change and the fossil resource depletion impact categories. The heavy weight of glass turns out to affect its environmental performances with respect to the light plastics, with reuse being an essential strategy to lower the burdens. The comparison between plastics and metals is more balanced, leaning more towards plastics for food packaging. Similarly, paper resulted often preferable than plastics. Finally, for the other materials (i.e. wood and textiles), the picture is variable. To be competitive with plastics, the alternative materials require improvements like the optimisation of their production processes, their reuse and enhanced end-of-life options. At the same time, recycled polymers could boost the eco-performance of virgin plastics.

Persistent SARS-CoV-2 infection with multiple clinical relapses in two patients with follicular lymphoma treated with bendamustine and obinutuzumab or rituximab.

PURPOSE: People with hematologic malignancies have a significantly higher risk of developing severe and protracted forms of SARS-CoV-2 infection compared to immunocompetent patients, regardless of vaccination status. RESULTS: We describe two cases of prolonged SARS-CoV-2 infection with multiple relapses of COVID-19 pneumonia in patients with follicular lymphoma treated with bendamustine and obinutuzumab or rituximab. The aim is to highlight the complexity of SARS-CoV-2 infection in this fragile group of patients and the necessity of evidence-based strategies to treat them properly. CONCLUSIONS: Patients with hematological malignancies treated with bendamustine and anti-CD20 antibodies had a significant risk of prolonged and relapsing course of COVID-19. Specific preventive and therapeutic strategies should be developed for this group of patients.

External Validity of a Randomized Controlled Trial on Duration of Antibiotics for the Treatment of Gram-Negative Bacteremia.

INTRODUCTION: Reports regarding the external validity of randomized controlled trials (RCTs) are scarce. We aimed to assess the population external validity of an investigator-initiated RCT on the duration of antibiotics for the treatment of Gram-negative bacteremia by comparing patients included in the RCT to patients that were not included in the trial. METHODS: Hospitalized patients with Gram-negative bacteremia were recruited into an RCT and randomized to receive 7 or 14 days of covering antibiotic therapy in Israel and Italy from 2013 to 2017. In a concomitant observational study, RCT participants were compared with patients who fulfilled the inclusion criteria but were not included in the trial due to participation in other trials, discharge before approached by researchers, refusal to participate, or unwillingness of the treating physician to allow participants' recruitment. RESULTS: Six hundred and four RCT patients were compared with 613 nonincluded patients. Almost 50% of nonincluded patients (288/613) were dependent on others for activities of daily living at baseline compared to 37.7% of RCT participants (228/604). Dementia was nearly 2-fold more frequent in nonincluded patients than those included (5.9% [36/613] versus 3.6% [22/604], p = 0.07). Patients who were not included in the RCT were more likely to acquire their infection in the hospital (53.3% [327/613] versus 29.1% [176/604], p < 0.001). The primary composite outcome of mortality, clinical failure, readmissions, or extended hospitalization at 90 days occurred in 353 of 613 nonincluded patients (57.6%) compared to 299 of 604 RCT participants (49.6%), p = 0.005. However, on multivariate analysis noninclusion in the RCT was not an independent risk factor for clinical failure and mortality. CONCLUSIONS: RCTs, even with broad eligibility criteria, do not represent the whole spectrum of patients and leave out a population with more severe illness for whom the evidence is lacking.

Intravenous methylprednisolone pulses in hospitalised patients with severe COVID-19 pneumonia: a double-blind, randomised, placebo-controlled trial.

RATIONALE: Pulse glucocorticoid therapy is used in hyperinflammation related to coronavirus disease 2019 (COVID-19). We evaluated the efficacy and safety of pulse intravenous methylprednisolone in addition to standard treatment in COVID-19 pneumonia. METHODS: In this multicentre, randomised, double-blind, placebo-controlled trial, 304 hospitalised patients with COVID-19 pneumonia were randomised to receive 1 g of methylprednisolone intravenously for three consecutive days or placebo in addition to standard dexamethasone. The primary outcome was the duration of patient hospitalisation, calculated as the time interval between randomisation and hospital discharge without the need for supplementary oxygen. The key secondary outcomes were survival free from invasive ventilation with orotracheal intubation and overall survival. RESULTS: Overall, 112 (75.4%) out of 151 patients in the pulse methylprednisolone arm and 111 (75.2%) of 150 in the placebo arm were discharged from hospital without oxygen within 30 days from randomisation. Median time to discharge was similar in both groups (15 days, 95% CI 13.0-17.0 days and 16 days, 95% CI 13.8-18.2 days, respectively; hazard ratio (HR) 0.92, 95% CI 0.71-1.20; p=0.528). No significant differences between pulse methylprednisolone and placebo arms were observed in terms of admission to intensive care unit with orotracheal intubation or death (20.0% versus 16.1%; HR 1.26, 95% CI 0.74-2.16; p=0.176) or overall mortality (10.0% versus 12.2%; HR 0.83, 95% CI 0.42-1.64; p=0.584). Serious adverse events occurred with similar frequency in the two groups. CONCLUSIONS: Methylprenisolone pulse therapy added to dexamethasone was not of benefit in patients with COVID-19 pneumonia.

Evaluation of the anaerobic degradation of food waste collection bags made of paper or bioplastic.

The amount of compostable bioplastics collected with the food waste is constantly growing, particularly due to the bags used for collection. According to the Italian legislation, compostable bioplastics must be accepted by all biological treatment plants, including aerobic and anaerobic facilities. Anyway, the compostability standard requires only the assessment of the aerobic degradability, while it is generally not required to test the behaviour under anaerobic conditions. This aspect is evaluated in the paper, where the anaerobic degradability of bioplastic bags used for the food waste collection is assessed. First, Biochemical Methane Potential (BMP) tests were performed on four commercial types of bioplastic bags, including those designed only for the collection of food waste and the shoppers, that can be reused for the same purpose. Subsequently, an innovative approach for this kind of substrate was applied, subjecting two bags to semi-continuous co-digestion tests together with the food waste. Both tests were performed by comparing the behaviour of bioplastic bags with that of an alternative collection paper bag. Finally, tests to evaluate the influence of physical phenomena on the degradation of bioplastics were performed to better understand the results of biological tests. BMP tests indicated a good degradability (>71%) of bioplastic bags, while semi-continuous tests showed a much lower degradability (<27%), confirmed by the observation of the undigested bag pieces. On the contrary, the paper bag presents interesting characteristics, because its degradability in the semi-continuous tests (82%) resulted even higher than that observed in the BMP tests (74%). These results highlight an important difference between the bags mono-digestion by means of BMP tests and the semi-continuous co-digestion tests with food waste, which better simulate the full-scale operational conditions.

High-dose glucocorticoids pulse-therapy for beta-coronaviridae pneumonia: a systematic literature review and case-series of Coronavirus disease-2019.

OBJECTIVES: The results of the RECOVERY trial identified dexamethasone as the first pharmacological therapy that reduces mortality in patients with COVID-19. The aim of this paper is to conduct a systematic literature review on safety and efficacy of pulse glucocorticoid therapy for Severe Acute Respiratory Syndrome (SARS)-CoronaVirus (CoV), Middle East Respiratory Syndrome (MERS)-CoV or SARS-CoV-2 infections and describe a case-series of COVID-19 patients treated with off-label pulse doses of methylprednisolone. METHODS: We performed a systematic literature review on safety and efficacy of pulse therapy for betacoronaviridae infections as described in the protocol registered on PROSPERO (CRD42020190183). All consecutive patients admitted to Arcispedale Santa Maria Nuova di Reggio Emilia or Guastalla Hospital with COVID-19 between March 1st and April 30th, 2020 and treated with methylprednisolone 1 gram/day for at least three days were included in the case series. A retrospective review of available computed tomography (CT) scan and chest x-ray was performed independently by two radiologists blinded to clinical data, and discordances were resolved by consensus. RESULTS: Twenty papers were included for SARS, but only two were comparative and were included in the primary endpoint analysis. Likewise, eleven papers were included for COVID-19, four of which were comparative and were considered for the primary outcome analysis. Included studies for both SARS and COVID-19 are mostly retrospective and highly heterogeneous, with lethality ranging from 0% to 100% and ICU admission rate ranging from 9% to 100%. Fourteen patients were included in our case series, 7 males and 7 females. CONCLUSIONS: No randomised controlled trial is available yet for corticosteroids pulse-therapy defined as at least ≥500mg/day methylprednisolone in patients with emerging coronavirus pneumonia. Lethality among our cohort is high (4/14), but this finding should be interpreted with caution due to the fact that in our setting pulse-steroids were used in patients not eligible for other treatments because of comorbidities or as rescue therapy. The incidence of steroid-related adverse events seems low in our cohort. The quality of the evidence on glucocorticoid pulse-therapy in SARS, MERS and COVID-19 is poor. Randomised controlled trials are greatly needed.

Life cycle assessment of the food waste management with a focus on the collection bag.

The organic fraction (mainly food waste) is typically the most abundant of the separately collected waste streams. The research aims at investigating the influence of different types of collection bag on the environmental performances of the food waste management chain in Italy. A comparative life cycle assessment (LCA) between two alternative systems based on paper or bioplastic collection bags was carried out. It included the collection bags manufacturing and distribution, their use at the household, the transportation of collected food waste and its subsequent anaerobic digestion, including the valorisation of useful outputs and the management of residues. The two systems were modelled mainly with primary data related to the current management system and to tests performed on bags. The LCA was performed with two different modelling approaches applied in the environmental product declaration (EPD) system and in the product environmental footprint (PEF) studies, respectively. In the scenario representing the average conditions, higher environmental impacts are shown by the use of bioplastic bags compared to paper ones with the EPD approach (+257%/+576%). With the PEF approach, the differences between the two systems are lower (-55%/+133%). Moreover, paper bags could allow for further impact reductions assuming a decrease of the food waste collection frequency, allowed by higher weight losses and a lower generation of leachate and odour during the household storage.

Abdominal Visceral Infarction in 3 Patients with COVID-19.

A high incidence of thrombotic events has been reported in patients with coronavirus disease (COVID-19), which is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. We report 3 clinical cases of patients in Italy with COVID-19 who developed abdominal viscera infarction, demonstrated by computed tomography.

Tocilizumab for patients with COVID-19 pneumonia. The single-arm TOCIVID-19 prospective trial.

BACKGROUND: Tocilizumab blocks pro-inflammatory activity of interleukin-6 (IL-6), involved in pathogenesis of pneumonia the most frequent cause of death in COVID-19 patients. METHODS: A multicenter, single-arm, hypothesis-driven trial was planned, according to a phase 2 design, to study the effect of tocilizumab on lethality rates at 14 and 30 days (co-primary endpoints, a priori expected rates being 20 and 35%, respectively). A further prospective cohort of patients, consecutively enrolled after the first cohort was accomplished, was used as a secondary validation dataset. The two cohorts were evaluated jointly in an exploratory multivariable logistic regression model to assess prognostic variables on survival. RESULTS: In the primary intention-to-treat (ITT) phase 2 population, 180/301 (59.8%) subjects received tocilizumab, and 67 deaths were observed overall. Lethality rates were equal to 18.4% (97.5% CI: 13.6-24.0, P = 0.52) and 22.4% (97.5% CI: 17.2-28.3, P < 0.001) at 14 and 30 days, respectively. Lethality rates were lower in the validation dataset, that included 920 patients. No signal of specific drug toxicity was reported. In the exploratory multivariable logistic regression analysis, older age and lower PaO2/FiO2 ratio negatively affected survival, while the concurrent use of steroids was associated with greater survival. A statistically significant interaction was found between tocilizumab and respiratory support, suggesting that tocilizumab might be more effective in patients not requiring mechanical respiratory support at baseline. CONCLUSIONS: Tocilizumab reduced lethality rate at 30 days compared with null hypothesis, without significant toxicity. Possibly, this effect could be limited to patients not requiring mechanical respiratory support at baseline. Registration EudraCT (2020-001110-38); clinicaltrials.gov (NCT04317092).

Acute-phase reactants during tocilizumab therapy for severe COVID-19 pneumonia.

OBJECTIVES: To identify predictors of clinical improvement and intubation/death in tocilizumab-treated severe COVID19, focusing on IL6 and CRP longitudinal monitoring. METHODS: 173 consecutive patients with severe COVID-19 pneumonia receiving tocilizumab in Reggio Emilia province Hospitals between 11 March and 3 June 2020 were enrolled in a prospective cohort study. Clinical improvement was defined as status improvement on a six-category ordinal scale or discharge from the hospital, whichever came first. A composite outcome of intubation/death was also evaluated. CRP and IL-6 levels were determined before TCZ administration (T0) and after 3 (T3), and 7 (T7) days. RESULTS: At multivariate analysis T0 and T3 CRP levels were negatively associated with clinical improvement (OR 0.13, CI 0.03-0.55 and OR 0.11, CI 0.0-0.46) (p=0.006 and p=0.003) and positively associated with intubation/death (OR 17.66, CI 2.47-126.14 and OR 5.34, CI: 1.49-19.12) (p=0.01 and p=0.004). No significant associations with IL-6 values were observed. General linear model analyses for repeated measures showed significantly different trends for CRP from day 3 to day 7 between patients who improved and those who did not, and between patients who were intubated or died and those who were not (p<0.0001 for both). ROC analysis identified a baseline CRP level of 15.8 mg/dl as the best cut-off to predict intubation/death (AUC = 0.711, sensitivity = 0.67, specificity = 0.71). CONCLUSIONS: CRP serial measurements in the first week of TCZ therapy are useful in identifying patients developing poor outcomes.

Role of Maraviroc in minimizing the risk of graft rejection in HIV-infected kidney transplant recipients.

BACKGROUND: Kidney transplantation in HIV-infected patients is characterized by a concerning high rate of allograft rejections. The etiological mechanisms leading to this increased immunoreactivity are still unknown. Maraviroc is a new antiretroviral agent that has been associated with immunomodulatory proprieties; therefore, its use may be a promising strategy to minimize the rate of rejections in HIV-infected kidney transplant (KT) recipients. METHODS: We conducted a retrospective study in our cohort of HIV-KT recipients with the aim to explore the effects of maraviroc in reducing the risk of graft rejection. RESULTS: Twenty-two HIV-infected KT recipients predominantly of Caucasian origin (86%) and with a median age of 49 (IQR, 51.9-42.2) years were evaluated. Ten HIV-infected patients were treated with maraviroc and 12 with a maraviroc-free antiretroviral regimen. After a median follow-up of 3.01 years, half of the maraviroc-treated patients (n = 5) developed seven episodes of graft rejection, most of them were T cell-mediated rejections (85.7%). Five episodes were recorded in the maraviroc-free group. The difference in the rate of graft rejections was not statistically significant (P = .23). CONCLUSIONS: The administration of maraviroc was ineffective in preventing graft rejections in our cohort of patients.

Bilateral Traumatic Caroticocavernous Fistulas: A Case Report and Review of the Literature.

A traumatic caroticocavernous fistula (CCF) is an acquired, abnormal communication between the internal carotid artery and the cavernous sinus, secondary to trauma. This rare condition can initially be misdiagnosed, because its presentation shares features common to those of facial trauma, which can result in serious complications. We describe a case of bilateral CCF in an adult patient after a road traffic accident.

Impact of polypharmacy on antiretroviral prescription in people living with HIV.

OBJECTIVES: To evaluate the relationship between polypharmacy and ART, delivered as conventional multi-tablet three-drug regimens, single-tablet regimens or less-drug regimens (simplified mono or dual regimens). METHODS: We conducted a cross-sectional analysis of electronic data from the prospective Modena HIV Metabolic Clinic Cohort Study. We included the last clinical observation for each patient from January 2006 to December 2015. Polypharmacy was defined as the use of five or more medications (excluding ART). Multi-morbidity was classified as the presence of two or more non-infectious comorbidities. Factors associated with different ART regimens were analysed using multivariable multinomial logistic regression analyses with multi-tablet three-drug regimens as the reference. RESULTS: A total of 2944 patients (33.7% females) were included in the analysis. Multinomial logistic regression analysis identified polypharmacy to be negatively associated with single-tablet regimens [relative risk reduction (RRR) = 0.48, 95% CI = 0.28-0.81] independently from frailty (RRR = 0.68, 95% CI = 0.59-0.78), after correction for age, gender, HIV infection duration, current and nadir CD4 and calendar year. This association was not found comparing multi-tablet three-drug regimens and less-drug regimens. CONCLUSIONS: Single-tablet regimens are less likely to be prescribed in patients with polypharmacy. Single-tablet regimens are perceived to be less flexible in patients with multi-morbidity and at higher risk of drug-drug interaction.

A frailty index predicts post-liver transplant morbidity and mortality in HIV-positive patients.

BACKGROUND: We hypothesized that frailty acts as a measure of health outcomes in the context of LT. The aim of this study was to explore frailty index across LT, as a measure of morbidity and mortality. This was a retrospective observational study including all consecutive 47 HIV+patients who received LT in Modena, Italy from 2003 to June 2015. METHODS: frailty index (FI) was constructed from 30 health variables. It was used both as a continuous score and as a categorical variable, defining 'most frail' a FI > 0.45. FI change across transplant (deltaFI, ΔFI) was calculated as the difference between year 1 FI (FI-Y1) and pre-transplant FI (FI-t0). The outcomes measures were mortality and "otpimal LT" (defined as being alive without multi-morbidity). RESULTS: Median value of FI-t0 was 0.48 (IQR 0.42-0.52), FI-Y1 was 0.31 (IQR 0.26-0.41). At year five mortality rate was 45%, "optimal transplant" rate at year 1 was 38%. All the patients who died in the post-LT were most frail in the pre-LT. ΔFI was a predictor of mortality after correction for age and MELD (HR = 1.10, p = 0.006) and was inversely associated with optimal transplant after correction for age (HR = 1.04, p = 0.01). CONCLUSIONS: We validated FI as a valuable health measure in HIV transplant. In particular, we found a relevant correlation between FI strata at baseline and mortality and a statistically significant correlation between, ΔFI and survival rate.

Late presentation increases risk and costs of non-infectious comorbidities in people with HIV: an Italian cost impact study.

BACKGROUND: Late presentation (LP) at the time of HIV diagnosis is defined as presentation with AIDS whatever the CD4 cell count or with CD4 <350 cells/mm. The objective of our study was to assess the prevalence of non-infectious comorbidities (NICM) and multimorbidity among HIV-positive individuals with and without a history of LP (HIV + LP and HIV + EP, respectively), and compare them to matched HIV-negative control participants from a community-based cohort. The secondary objective was to provide estimates and determinants of direct cost of medical care in HIV patients. METHODS: We performed a matched cohort study including HIV + LP and HIV + EP among people attending the Modena HIV Metabolic Clinic (MHMC) in 2014. HIV-positive participants were matched in a 1:3 ratio with HIV-negative participants from the CINECA ARNO database. Multimorbidity was defined as the concurrent presence of ≥2 NICM. Logistic regression models were constructed to evaluate associated predictors of NICM and multimorbidity. RESULTS: We analyzed 452 HIV + LP and 73 HIV + EP participants in comparison to 1575 HIV-negative controls. The mean age was 46 ± 9 years, 27.5% were women. Prevalence of NICM and multimorbidity were fourfold higher in the HIV + LP compared to the general population (p < 0.001), while HIV + EP present an intermediate risk. LP was associated with increased total costs in all age strata, but appear particularly relevant in patients above 50 years of age, after adjusting for age, multimorbidity, and antiretroviral costs. CONCLUSIONS: LP with HIV infection is still very frequent in Italy, is associated with higher prevalence of NICM and multimorbidity, and contributes to higher total care costs. Encouraging early testing and access to care is still urgently needed.

Packaging waste prevention in the distribution of fruit and vegetables: An assessment based on the life cycle perspective.

In recent years, alternative food supply chains based on short distance production and delivery have been promoted as being more environmentally friendly than those applied by the traditional retailing system. An example is the supply of seasonal and possibly locally grown fruit and vegetables directly to customers inside a returnable crate (the so-called 'box scheme'). In addition to other claimed environmental and economic advantages, the box scheme is often listed among the packaging waste prevention measures. To check whether such a claim is soundly based, a life cycle assessment was carried out to verify the real environmental effectiveness of the box scheme in comparison to the Italian traditional distribution. The study focused on two reference products, carrots and apples, which are available in the crate all year round. An experience of a box scheme carried out in Italy was compared with some traditional scenarios where the product is distributed loose or packaged at the large-scale retail trade. The packaging waste generation, 13 impact indicators on environment and human health and energy consumptions were calculated. Results show that the analysed experience of the box scheme, as currently managed, cannot be considered a packaging waste prevention measure when compared with the traditional distribution of fruit and vegetables. The weaknesses of the alternative system were identified and some recommendations were given to improve its environmental performance.

Life cycle assessment and cost analysis of an innovative automatic system for sorting municipal solid waste: A case study at Milan Malpensa airport.

With the recent advancement in artificial intelligence, there are new opportunities to adopt smart technologies for the sorting of materials at the beginning of the recycling value chain. An automatic bin capable of sorting the waste among paper, plastic, glass & aluminium, and residual waste was installed in public areas of Milan Malpensa airport, a context where the separate collection is challenging. First, the airport waste composition was assessed, together with the efficiency of the manual sorting performed by passengers among the conventional bins: paper, plastic, glass & aluminium, and residual waste. Then, the environmental (via the life cycle assessment - LCA) and the economic performances of the current system were compared to those of a system in which the sorting is performed by the automatic bin. Three scenarios were evaluated: i) all waste from public areas, despite being separately collected, is sent to incineration with energy recovery, due to the inadequate separation quality (S0); ii) recyclable fractions are sent to recycling according to the actual level of impurities in the bags (S0R); iii) fractions are sorted by the automatic bin and sent to recycling (S1). According to the results, the current separate collection shows a 62 % classification accuracy. Focusing on LCA, S0 causes an additional burden of 12.4 mPt (milli points) per tonne of waste. By contrast, S0R shows a benefit (-26.4 mPt/t) and S1 allows for a further 33 % increase of benefits. Moreover, the cost analysis indicates potential savings of 24.3 €/t in S1, when compared to S0.