Biomass gasification technology:The state of the art overview

In the last decades the interest in the biomass gasification process has increased due to the growing attention to the use of sustainable energy. Biomass is a renewable energy source and represents a valid alternative to fossil fuels. Gasification is the thermochemical conversion of an organic material into a valuable gaseous product, called syngas, and a solid product, called char. The biomass gasification represents an efficient process for the production of power and heat and the production of hydrogen and second-generation biofuels.This paper deals with the state of the art biomass gasification technologies, evaluating advantages and disadvantages, the potential use of the syngas and the application of the biomass gasification. Syngas cleaning though fundamental to evaluate any gasification technology is not included in this paper since; in the authors' opinion, a dedicated review is necessary.

Fat:A matter of disturbance for the immune system

Obesity is increasingly being recognized as a risk factor for a number of benign and malignant gastrointestinal conditions. However, literature on the underlying pathophysiological mechanisms is sparse and ambiguous. There is compelling evidence that both overnutrition and undernutrition negatively interfere with the immune system. Overnutrition has been found to increase susceptibility to the development of inflammatory diseases, autoimmune diseases and cancer. In the regulation of immune and in? ammatory processes, white adipose tissue plays a critical role, not only as an energy store but also as an important endocrine organ. The obese state is characterised by a low-grade systemic in? ammation, mainly as a result of increased adipocytes as well as fat resident-and recruited-macrophage activity. In the past few years, various products of adipose tissue including adipokines and cytokines have been characterised and a number of pathways linking adipose tissue metabolism with the immune system have been identified. Activation of the innate immune system plays a major role in hepatic steatosis. Non-alcoholic fatty liver disease includes a wide spectrum of diseases, from pure steatosis to non-alcoholic steato-hepatitis in the absence of signif icant alcohol consumption. Although steatosis is considered a non-progressive disease, non-alcoholic steatohepatitis may deteriorate in advanced chronic liver diseases, cirrhosis, and hepatocellular carcinoma. An important parallel between obesityrelated pathology of adipose tissue and liver pertains to the emerging role of macrophages, and growing evidence suggests that Kupffer cells critically contribute to progression of non-alcoholic fatty liver disease. Moreover, a close link between specif ic immune activation and atherosclerosis has been well established, suggesting that fat can directly trigger immune responses. This review discusses the role of fat as "a matter of disturbance for the immune system" with a focus on hepatic steatosis.

Treatment of esophagogastric junction carcinoma:An unsolved debate

The incidence of esophagogastric junction adenocarcinoma(AEG) is increasing worldwide. Barrett's esophagus(BE) associated with dysplasia is the main risk factor for the development of cancer. Currently, screening programs to individuate and eradicate BE represent the best way to reduce AEG cancer. Several endoscopic approaches are here discussed. Surgicalstrategies for different types of AEG cancer are now fairly standardized, and multidisciplinary strategies u s i n g c h e m o t h e ra py o r c h e m o ra d i o t h e ra py m ay improve the outcome of these patients. Here we briefly discuss the keypoints, main topics, and critical issues, according to accumulating evidence and taking into account our own experience.

Clinical management of advanced gastric cancer: The role of new molecular drugs

Gastric cancer is the fourth most common malignant neoplasm and the second leading cause of death for cancer in Western countries with more than 20000 new cases yearly diagnosed in the United States.Surgery represents the main approach for this disease but,notwithstanding the advances in surgical techniques,we observed a minimal improvement in terms of overall survival with a significant increasing of relapsing disease rates.Despite the development of new drugs has significantly improved the effectiveness of chemothera-py,the prognosis of patients with unresectable or metastatic gastric adenocarcinoma remains poor.Recently,several molecular target agents have been investigated;in particular,trastuzumab represents the first target molecule showing improvements in overall survival in human epithelial growth factor 2-positive gastric cancer patients.New molecules targeting vascular epithelial growth factor,mammalian target of rapamycin,and anti hepatocyte growth factor-c-Met pathway are also under investigation,with interesting results.Anyway,it seems necessary to select more accurately the population to treat with new agents by the identification of new biomarkers in order to optimize the results.In this paper we review the actual"scenario"of targeted treatments,also focusing on the new agents in development for gastric cancer and gastro-esophageal carcinoma,discussing their efficacy and potential applications in clinical practice.

Pathogenesis and significance of hepatitis C virus steatosis:An update on survival strategy of a successful pathogen

Hepatitis C virus(HCV)is a successful pathogen on the grounds that it exploits its host’s metabolism to build up viral particles;moreover it favours its own survival by inducing chronic disease and the development of specific anatomic changes in the infected organ.Steatosis,therefore,is associated with HCV infection by necessity rather than by chance alone.Approximately6%of HCV patients have steatohepatitis.Interestingly,HCV steatosis occurs in the setting of multiple metabolic abnormalities(hyperuricemia,reversible hypocholesterolemia,insulin resistance,arterial hypertension and expansion of visceral adipose tissue)collectively referred to as"hepatitis C-associated dysmetabolic syndrome"(HCADS).General,nonalcoholic fatty liver disease(NAFLD)-like,mechanisms of steatogenesis(including increased availability of lipogenic substrates and de novo lipogenesis;decreased oxidation of fatty substrates and export of fatty substrates)are shared by all HCV genotypes.However,genotype 3 seemingly amplifies such steatogenic molecular mechanisms reported to occur in NAFLD via more profound changes in microsomal triglyceride transfer protein;peroxisome proliferator-activated receptor alpha;sterol regulatory element-binding proteins and phosphatase and tensin homologue.HCV steatosis has a remarkable clinical impact in as much as it is an acknowledged risk factor for accelerated fibrogenesis;for impaired treatment response to interferon and ribavirin;and development of hepatocellular carcinoma.Recent data,moreover,suggest that HCV-steatosis contributes to premature atherogenesis via both direct and indirect mechanisms.In conclusion,HCV steatosis fulfills all expected requirements necessary to perpetuate the HCV life cycle.A better understanding of the physiology of HCADS will likely result in a more successful handling of disease with improved antiviral success rates.

Role of occult hepatitis B virus infection in chronic hepatitis C

The development of sensitive assays to detect small amounts of hepatitis B virus(HBV) DNA has favored the identification of occult hepatitis B infection(OBI), a virological condition characterized by a low level of HBV replication with detectable levels of HBV DNA in liver tissue but an absence of detectable surface antigen of HBV(HBs Ag) in serum. The gold standard to diagnose OBI is the detection of HBV DNA in the hepatocytes by highly sensitive and specific techniques, a diagnostic procedure requiring liver tissue to be tested and the use of non-standardized non-commercially available techniques. Consequently, in everyday clinical practice, the detection of anti-hepatitis B core antibody(antiHBc) in serum of HBs Ag-negative subjects is used as a surrogate marker to identify patients with OBI. In patients with chronic hepatitis C(CHC), OBI has been identified in nearly one-third of these cases. Considerable data suggest that OBI favors the increase of liver damage and the development of hepatocellular carcinoma(HCC) in patients with CHC. The data from other studies, however, indicate no influence of OBI on the natural history of CHC, particularly regarding the risk of developing HCC.

Clinical expression of insulin resistance in hepatitis C and B virus-related chronic hepatitis:Differences and similarities

AIM:To investigate the prevalence of the clinical parameters of insulin resistance and diabetes in patients affected by chronic hepatitis C(CHC) or chronic hepatitis B(CHB) . METHODS:We retrospectively evaluated 852 consecutive patients(726 CHC and 126 CHB) who had undergone liver biopsy.We recorded age,sex,ALT,type 2 diabetes and/or metabolic syndrome(MS) ,body mass index(BMI) ,and apparent disease duration(ADD) . RESULTS:Age,ADD,BMI,prevalence of MS and diabetes in patients with mild/moderate liver fibrosis were significantly higher in CHC.However,the degree of steatosis and liver fibrosis evaluated in liver biopsies did not differ between CHC and CHB patients.At multivariate analysis,age,sex,BMI,ALT and diabetes were independent risk factors for liver fibrosis in CHC,whereas only age was related to liver fibrosis in CHB. We also evaluated the association between significant steatosis(>30%) and age,sex,BMI,diabetes,MS and liver fibrosis.Diabetes,BMI and liver fibrosis were associated with steatosis>30%in CHC,whereas only age and BMI were related to steatosis in CHB. CONCLUSION:These data may indicate that hepatitis C virus infection is a risk factor for insulin resistance.

Clinical significance of hepatitis B surface antigen mutants

Hepatitis B virus(HBV) infection is a major public health problem in many countries, with nearly 300 million people worldwide carrying HBV chronic infection and over 1 million deaths per year due to cirrhosis and liver cancer. Several hepatitis B surface antigen(HBs Ag) mutations have been described, most frequently due to a single amino acid substitution and seldom to a nucleotide deletion. The majority of mutations are located in the S region, but they have also been found in the pre-S1 and pre-S2 regions. Single amino acid substitutions in the major hydrophilic region of HBs Ag, called the "a" determinant, have been associated with immune escape and the consequent failure of HBV vaccination and HBs Ag detection, whereas deletions in the pre-S1 or pre-S2 regions have been associated with the development of hepatocellular carcinoma. This review article will focus on the HBs Ag mutants and their biological and clinical implications.

Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation(Part Ⅱ:Treatment)

The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation.There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation.Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre.Osmotic laxatives may be effective in patients who do not respond to fibre supplements.Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives.Controlled trials have shown that serotoninergic enterokinetic agents,such as prucalopride,and prosecretory agents,such as lubiprostone,are effective in the treatment of patients with chronic constipation.Surgery is sometimes necessary.Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders,generalised motility disorders or psychological disorders.Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation.Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects,but none is considered to be the gold standard.Surgery should be reserved for selected patients with an impaired quality of life.Obstructed defecation is often associated with pelvic organ prolapse.Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse,but the efficacy and safety of such procedures have not yet been established.

Eradication of Helicobacter pylori infection:Which regimen first?

Helicobacter pylori(H.pylori)is a well-known human pathogen that plays an essential role in the pathogenesis of chronic gastritis,peptic ulcer disease,and gastric malignancies.Although H.pylori is susceptible to several antimicrobials,this infection has proven challenging to cure because of the increasing prevalence of bacterial strains that are resistant to the most commonly used antimicrobials,particularly clarithromycin.An effective(i.e.,>90%)first-line therapy is mandatory for avoiding supplementary treatments and testing,and more importantly for preventing the development of secondary resistance.This study reviews the recent literature on first-line therapies forH.pylori.The eradication rates following standard triple therapy(a proton pump inhibitor plus amoxicillin and clarithromycin)for H.pylori infection are declining worldwide.Several first-line strategies have been proposed to increase the eradication rate,including extending the treatment duration to 14 d,the use of a four-drug regimen(bismuth-containing quadruple,sequential,and concomitant treatments),and the use of novel antibiotics,such as fluoroquinolones.However,the ef5ficacy of these regimens is controversial.A first-line eradication regimen should be based on what works best in a defined geographical area and must take into account the prevalence of antimicrobial resistance in that region.

Prevalence of bile reflux in gastroesophageal reflux disease patients not responsive to proton pump inhibitors

AIM:To determine the prevalence and characteristics of bile reflux in gastroesophageal reflux disease(GERD) patients with persistent symptoms who are non-responsive to medical therapy.METHODS:Sixty-five patients(40 male,25 female;mean age,50 ± 7.8 years) who continued to report symptoms after 8 wk of high-dose proton pump inhibitor(PPI) therapy,as well as 18 patients with Barrett's esophagus,were studied.All patients filled out symptom questionnaires and underwent endoscopy,manometry and combined pH-metry and bilimetry.RESULTS:There were 4 groups of patients:22(26.5%) without esophagitis,24(28.9%) grade A-B esophagitis,19(22.8%) grade C-D and 18(21.6%) Barrett's esophagus.Heartburn was present in 71 patients(85.5%) and regurgitation in 55(66.2%),with 44(53%) reporting simultaneous heartburn and regurgitation.The prevalence of pathologic acid reflux in the groups without esophagitis and with grades A-B and C-D esophagitis was 45.4%,66.6% and 73.6%,respectively.The prevalence of pathologic bilirubin exposure in these 3 groups was 53.3%,75% and 78.9%,respectively.The overall prevalence of bile reflux in non-responsive patients was 68.7%.Pathologic acid and bile reflux was observed in 22.7% and 58.1% of non-esophagitic patients and esophagitic patients,respectively.CONCLUSION:The high percentage of patients poorly responsive to PPI therapy may result from poor control of duodenogastroesophageal reflux.Many patients without esophagitis have simultaneous acid and bile reflux,which increases with increasing esophagitis grade.

Magnetic resonance imaging:A new tool for diagnosis of acute ischemic colitis?

AIM:To define the evolution of ischemic lesions with 7T magnetic resonance imaging(7T-MRI)in an animal model of acute colonic ischemia.METHODS:Adult Sprague-Dawley rats were divided into two groups.GroupⅠ underwent inferior mesenteric artery(IMA)ligation followed by macroscopic observations and histological analysis.In groupⅡ,7T-MRI was performed before and after IMA ligation and followed by histological analysis.RESULTS:Morphological alterations started to develop 1 h after IMA ligation,when pale areas became evident in the splenic flexure mesentery and progressively worsened up to 8 h thereafter,when the mesentery was less pale,and the splenic flexure loop appeared very dark.The 7T-MRI results reflected these alterations,showing a hyperintense signal in both the intraperitoneal space and the colonic loop wall 1 h after IMA ligation;the latter progressively increased to demonstrate a reduction in the colonic loop lumen at 6 h.Eight hours after IMA ligation,MRI showed a persistent colonic mural hyperintensity associated with a reduction in peritoneal free fluid.The 7T-MRI findings were correlated with histological alterations,varying from an attenuated epithelium with glandular apex lesions at 1 h to coagulative necrosis and loss of the surface epithelium detected 8 h after IMA ligation.CONCLUSION:MRI may be used as a substitute for invasive procedures in diagnosing and grading acute ischemic colitis,allowing for the early identification of pathological findings.

Consensus statement AIGO/SICCR:Diagnosis and treatment of chronic constipation and obstructed defecation(partⅠ:Diagnosis)

Chronic constipation is a common and extremely troublesome disorder that significantly reduces the quality of life,and this fact is consistent with the high rate at which health care is sought for this condition.The aim of this project was to develop a consensus for the diagnosis and treatment of chronic constipation and obstructed defecation.The commission presents its results in a "Question-Answer" format,including a set of graded recommendations based on a systematic review of the literature and evidence-based medicine.This section represents the consensus for the diagnosis.The history includes information relating to the onset and duration of symptoms and may reveal secondary causes of constipation.The presence of alarm symptoms and risk factors requires investigation.The physical examination should assess the presence of lesions in the anal and perianal region.The evidence does not support the routine use of blood testing and colonoscopy or barium enema for constipation.Various scoring systems are available to quantify the severity of constipation;the Constipation Severity Instrument for constipation and the obstructed defecation syndrome score for obstructed defecation are the most reliable.The Constipation-Related Quality of Life is an excellent tool for evaluating the patient's quality of life.No single test provides a pathophysiological basis for constipation.Colonic transit and anorectal manometry define the pathophysiologic subtypes.Balloon expulsion is a simple screening test for defecatory disorders,but it does not define the mechanisms.Defecography detects structural abnormalities and assesses functional parameters.Magnetic resonance imaging and/or pelvic floor sonography can further complement defecography by providing information on the movement of the pelvic floor and the organs that it supports.All these investigations are indicated to differentiate between slow transit constipation and obstructed defecation because the treatments differ between these conditions.

Soil quality assessment across different stands in tropical moist deciduous forests of Nagaland,India

To analyze the relationship between the management of three forest stand plantations and soil quality in the Dimapur district of the Northeastern Himalayan region,India,three forest soil profiles,covered by different species stands,at three depths were tested for 13 physical and chemical variables.Only four of these variables(electric conductivity,bulk density exchangeable Mg and available P)were included in a minimum data set,after using a varimax rotation algorithm in a principal component analysis,and subsequently used to calculate a soil quality index(SQI).Results showed higher SQIs in the surface layers(0–20 cm depth)than in the deeper ones.Average weighed SQI varied significantly(P<0.05)through the three considered forest sites,with the lowest value at site FS3.These findings reveal that the approach used here is suitable for preliminary screening of the impact of a forestry species on soil,to aid in species selection and improve soil health for afforestation and reforestation projects.

Clinical features and natural history of cryptogenic cirrhosis compared to hepatitis C virus-related cirrhosis

AIM To characterize natural history of cryptogenic cirrhosis(CC) and compare its clinical features and outcomes to those of hepatitis C virus(HCV)-related cirrhosis.METHODS A prospective cohort of 102 consecutive patients at their first diagnosis of CC were enrolled in this study. The clinical data and outcomes were compared to an ageand Child-pugh class-matched cohort of 110 patients with HCV-related cirrhosis. Diagnosis of cirrhosis was based on compatible clinical and laboratory parameters, ultrasound/endoscopic parameters and, whenever possible, on histological grounds and transient elastography. All cases of cirrhosis without a definite etiology were enrolled in the CC group. The parameters assessed were:(1) severity of liver disease at the time of first diagnosis;(2) liver decompensation during follow-up;(3) hepatocellular carcinoma(HCC);(4) orthotopic liver transplantation; and(5) death. The independent associated factors were evaluated by multiple logistic regression analysis, and survival and its determinants by the Kaplan-Meier model, log-rank test and Cox regression.RESULTS At the first observation, median age was 66 and 65 years and male gender was 36% and 58% for CC and HCV cirrhosis, respectively. CC showed Child-pugh class A/B/C of 47%/31%/22%, respectively. Compared to HCV cirrhosis, CC exhibited a significantly higher prevalence of metabolic syndrome(12% vs 54%, respectively), overweight/obesity, high BMI, impaired glucose tolerance, high blood pressure, dyslipidemia, hyperuricemia, cardiovascular diseases, extrahepatic cancer, and gallstones. Over a median period of 42 mo of follow-up, liver decompensation, HCC development and death for CC and HCV-related cirrhosis were 60.8%, and 54.4%, 16.7% and 17.2%, 39.2% and 30%, respectively. The median survival was 60 mo for CC. Independent predictors of death were age and Childpugh class at diagnosis. CC showed an approximately twofold higher incidence of HCC in Child-pugh class A.CONCLUSION Undiagnosed nonalcoholic fatty liver disease has an etiologic role in CC that is associated with a poor prognosis, early HCC development, high risk of cardiovascular disease and extrahepatic cancer.

Impact of comorbidities on the severity of chronic hepatitis B at presentation

AIM:To evaluate the clinical relevance of each cofactor on clinical presentation of chronic hepatitis B.METHODS:Out of 1366 hepatitis B surface antigen(HBsAg) positive subjects consecutively observed in 79 Italian hospitals,53(4.3%) showed as the only cofactor hepatitis D virus(HDV) infection [hepatitis B virus(HBV)/HDV group],130(9.5%) hepatitis C virus(HCV)(group HBV/HCV),6(0.4%) human immunodeficiencyvirus(HIV)(group HBV/HIV),138(10.2%) alcohol abuse(group HBV/alcohol);109(8.0%) subjects had at least two cofactors and 924 were in the cofactor-free(CF) group.RESULTS:Compared with patients in group CF those in group HBV/alcohol were older and more frequently had cirrhosis(P < 0.001),those in group HBV/HDV were younger(P < 0.001),more frequently resided in the south of the country and had cirrhosis(P <0.001),those in group HBV/HCV were older(P < 0.001) and more frequently had cirrhosis(P < 0.001).These cofactors were all independent predictors of liver cirrhosis in HBsAg positive patients.Multivariate analysis showed that an older age [odds ratio(OR) 1.06,95% CI:1.05-1.08],alcohol abuse with more than 8 drinks daily(OR 2.89,95% CI:1.81-4.62) and anti-HDV positivity(OR 3.48,95% CI:2.16-5.58) are all independently associated with liver cirrhosis.This association was found also for anti-HCV positivity in univariate analysis,but it was no longer associated(OR 1.23,95% CI:0.84-1.80) at multivariate analysis.CONCLUSION:Older age,HDV infection and alcohol abuse are the major determinants of severe liver disease in chronic HBV infection,while HCV replication plays a lesser role in the severity of hepatic damage.

Visual outcome after removal of silicone oil in patients undergoing retinectomy for complex retinal detachment

AIM:To evaluate the functional outcome after removal of silicone oil(ROSO)in patients undergoing retinectomy for complex retinal detachment.·METHODS:We performed a retrospective case note review of patients who underwent ROSO after retinectomy for complex retinal detachment.Patients with less than 6mo follow up and recurrent retinal detachment following ROSO were excluded.·RESULTS:Thirty-six patients were included.The mean best corrected visual acuity(BCVA)pre-ROSO was1.13 log MAR(SD 0.5).The mean BCVA 3mo following ROSO was 1.16 log MAR(SD 0.53),6mo following ROSO1.13(SD 0.63),and 12mo following ROSO 1.18(SD 0.69).At 12mo after ROSO,the BCVA improved in 38.9%of patients,remained unchanged in 25%,and deteriorated in 36.1%,although there was no statistical significant difference in BCVA after ROSO at 3,6 and 12mo(P=0.93).The size of retinectomy ranged from 15°to 270°(SD 53)and did not influence the visual outcome(P=0.11).·CONCLUSION:There was no statistically significant difference in BCVA between pre-and post-ROSO following retinectomy for complex retinal detachment.There was no statistical difference in visual outcome related to the size of the retinectomy.

Investigation of compensatory postures with videofluoromanometry in dysphagia patients

AIM: To investigate the effectiveness of head compensatory postures to ensure safe oropharyngeal transit. METHODS: A total of 321 dysphagia patients were enrolled and assessed with videofluoromanometry (VFM). The dysphagia patients were classified as follows: safe transit; penetration without aspiration; aspiration before, during or after swallowing; multiple aspirations and no transit. The patients with aspiration or no transit were tested with VFM to determine whether compensatory postures could correct their swallowing disorder. RESULTS: VFM revealed penetration without aspiration in 71 patients (22.1%); aspiration before swallowing in 17 patients (5.3%); aspiration during swallowing in 32 patients (10%); aspiration after swallowing in 21 patients (6.5%); multiple aspirations in six patients (1.9%); no transit in five patients (1.6%); and safe transit in 169 patients (52.6%). Compensatory postures guaranteed a safe transit in 66/75 (88%) patients with aspiration or no transit. A chin-down posture achieved a safe swallow in 42/75 (56%) patients, a head-turned posture in 19/75 (25.3%) and a hyperextended head posture in 5/75 (6.7%). The compensatory postures were not effective in 9/75 (12%) cases. CONCLUSION: VFM allows the speech-language therapist to choose the most effective compensatory posture without a trial-and-error process and check the effectiveness of the posture.

Clinical effectiveness of palifermin in prevention and treatment of oral mucositis in children with acute lymphoblastic leukaemia: a case–control study

The aim of this study was to evaluate the efficacy of palifermin, an N-terminal truncated version of endogenous keratinocyte growth factor, in the control of oral mucositis during antiblastic therapy. Twenty patients undergoing allogeneic stem-cell transplantation for acute lymphoblastic leukaemia were treated with palifermin, and compared to a control group with the same number of subjects and similar inclusion criteria. Statistical analysis were performed to compare the outcomes in the treatment vs. control groups. In the treatment group, we found a statistically significant reduction in the duration of parenteral nutrition(P50.002), duration of mucositis(P50.003) and the average grade of mucositis(P50.03). The statistical analysis showed that the drug was able to decrease the severity of mucositis. These data, although preliminary, suggest that palifermin could be a valid therapeutic adjuvant to improve the quality of life of patients suffering from leukaemia.

Epidemiology of acute and chronic hepatitis B and delta over the last 5 decades in Italy

The spread of hepatitis B virus(HBV)infection has gradually decreased in Italy in the last 5 decades as shown by the steady reduction in the incidence rates of acute hepatitis B,from 10/100000 inhabitants in1984 to 0.85/100000 in 2012,and by the reduced prevalence of hepatitis B surface antigen(HBsAg)-positive cases among chronic hepatitis patients with different etiologies,from 60%in 1975 to about 10%in 2001.The prevalence of HBsAg chronic carriers in the general population also decreased from nearly 3%in the 1980s to 1%in 2010.Linked to HBV by its characteristics of defective virus,the hepatitis delta virus(HDV)has shown a similar epidemiological impact on the Italian population over time.The incidence of acute HDV infection decreased from 3.2/100000 inhabitants in 1987 to 0.8/100000 in 2010 and the prevalence of HDV infection in HBsAg chronic carriers decreased from24%in 1990 to 8.5%in 2006.Before the beneficial effects of HBV mass vaccination introduced in 1991,the decreased endemicity of HBV and HDV infection in Italy paralleled the improvement in screening blood donations,the higher standard of living and impressive reduction in the birth rate associated with a marked reduction in the family size.A further contribution to the decline in HBV and HDV infections most probably came from the media campaigns to prevent the spread of human immunodeficiency virus infection by focusing the attention of the general population on the same routes of transmission of viral infections such as unsafe sexual intercourse and parenteral exposures of different kinds.