Vestibular migraine is a condition that associates headache and vestibular symptoms.To evaluate body-balance with virtual reality posturography in vestibular migraine.MT  posturography with 30 controls, paired for age and gender.A total of 26 patients in the intercritical period of vestibular migraine were compared by means of the Balance Rehabilitation Unitp = 0.121) in the limit of stability area (cm2) between the experimental group and the control group values. There were significant differences (p < 0.05) in the values of sway velocity (cm/s) in nine of ten evaluated sensory conditions and in the pressure center displacement area (cm2) values in eight of those ten sensory conditions in the comparison between the control group and the experimental group.There was no significant statistical difference (Posturography with virtual reality can identify changes in the sway velocity and the pressure center displacement area, characterizing the inability to maintain postural control with and without visual deprivation in situations of visual conflict and vestibulovisual interaction,in the intercritical period of the vestibular migraine. Vestibular migraine is a clinical condition that associates migraine headache and vestibular symptoms,Vestibular migraine is estimated to occur in approximately 1% of the general population throughout life.The initially proposed criteria for the diagnosis of vestibular migraine9The diagnosis of vestibular migraine is based on recurrent vestibular symptoms, such as different types of vertigo or dizziness, with nausea, of moderate or severe intensity, lasting from 5 min to 72 h; history of current or past migraine, with or without aura; temporal association between vestibular symptoms and migraine symptoms; and, exclusion of other causes of vestibular complaints. In approximately 50% of the vestibular episodes, migraine may present with a headache, with at least two of the following characteristics: unilateral, pulsatile, moderate or severe, aggravated by routine physical activities or exercises; and/or with photophobia and phonophobia.Clinical evaluation and laboratory or functional assessment of patients with vestibular migraine may reveal signs of vestibular dysfunction, which are not pathognomonic of the condition.Different types of posturography have been used to evaluate the postural control of patients with migraine and vestibular dysfunction, identifying somatosensory, vestibular and visual alterations, isolated or combined,Virtual reality is a type of artificial immersion in a safe and controlled environment, which has the ability to expose the patient to sensory conflicts at different levels of difficulty.In virtual reality, the perception of the environment is modified by the repetitive presentation of visual and proprioceptive stimuli, resulting in sensory conflicts that have an effect on vestibuloocular and vestibulospinal reflexes involved in postural control and in body balance strategies.18Considering the scarcity of controlled studies in vestibular migraine and that posturography with virtual reality analyzes the effects of visual, somatosensory and vestibular stimuli on body balance maintenance, the interest in assessing the usefulness of this instrument developed, aiming to identify signs of postural control alterations in patients with this complex condition, very frequently observed in the interval between vertiginous episodes. The hypothesis for this study is that patients with vestibular migraine, even during the intercritical period of the condition, may be unable to maintain postural control when submitted to visual, somatosensory and vestibular stimuli.The aim of this investigation is to evaluate patients’ postural control at posturography with virtual reality in the intercritical period of vestibular migraine.This descriptive and analytical cross-sectional study was carried out from 2016 to 2017 in the Otology and Neurotology Discipline of the Department of Otorhinolaryngology Head and Neck Surgery of Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EFM), after approval by the Research Ethics Committee of the institution under number 1,873,209. All participants received information about the study and its objectives through an explanatory letter and signed the Free and Informed Consent Form before the investigation started. For the evaluation of body balance, the sample consisted of an experimental group of patients, which was sequentially selected, with a diagnosis of vestibular migraine established by an otorhinolaryngologist, in the intercritical period of the condition, and by a control group consisting of healthy individuals with no previous personal history and family history of migraine, comprising community volunteers, homogeneous regarding age and gender in relation to the experimental group.The inclusion criteria for the control subjects were: healthy individuals, without symptoms, personal or family history of vestibular migraine or neurological, vestibular, auditory or other chronic diseases that could lead to balance alterations. Individuals who did not meet the inclusion criteria of this study were excluded from the research protocol.The inclusion criterion for the experimental group consisted of male and female patients, between 18 and 64 years of age, with a diagnosis of vestibular migraine, who were selected from the vestibular migraine outpatient clinicPatients from the experimental group underwent otorhinolaryngological examination; anamnesis; were submitted to the Brazilian versionThe DHI evaluated the impact of dizziness on the patient's quality of life. The DHI consists of twenty-five questions; seven on physical, nine on emotional, and nine on functional aspects. In each question, the patients answered yes, sometimes or no, corresponding to 4, 2 or 0 (zero) points, respectively. The total score ranges from (0) zero to 100 points, having 28 points as the maximum score for the physical aspect questions, 36 points for the emotional aspect and 36 points for the functional aspect. The DHI analysis classified the impact of symptoms on quality of life as mild, when the score was between (0) zero and 30, moderate between 31 and 60 and severe between 61 and 100 points.The visual analog scale of vertigo and/or dizziness measured the intensity of these symptoms to quantify the degree of patient discomfort, through a score ranging from (0) zero to 10 on a scale, with 0 (zero) being the lowest intensity and 10 (ten) the highest intensity of symptom level.The experimental and the control groups underwent body balance evaluation through the posturography module integrated to visual stimuli, projected in BRU™ virtual reality goggles. This posturography test evaluates the interaction between the visual, somatosensory and vestibular systems, measures postural sway resulting from exposure to different conditions on firm ground, on unstable surface with open eyes and closed eyes; and, visual stimulation, with or without head movements, that generates saccadic, optokinetic, vestibuloocular and vestibulospinal reflexes. The available visual stimuli, according to the calibrated oculomotor reflex, are: foveal , retinal (linear optokinetic bars) and sensory interaction .The equipment includes a computer with the BRU™ program; metallic safety structure; protector bracket with straps and seat belt; fixed force platform; virtual reality googles ; accelerometer and unstable polyurethane foam surface with 14 cm-high density.The posturography performed with the BRU™ provided information on the individual's pressure center position through quantitative indicators: limit of the stability area, pressure center area and sway velocity under ten sensory conditions. The limit of the stability area was measured by approximation of the sway pattern of an ellipse using the maximum and minimum total displacements to the right, to the left, forward and backward. The pressure center area was defined as the area of distribution of 95% of the samples of the pressure center; and the mean sway velocity was established by the total distance covered by the pressure center and divided by the time of 60 s of the test.In a quiet room measuring approximately six square meters, the test was performed with the patient standing upright on the platform, barefoot, arms extended along the body, with the right and left internal malleoli positioned at the extremities of the intermaleolar line and the two first toes 10° apart from the midline.A foot moldThe mean time for the complete evaluation with the BRU™was approximately 11 min, with 60 s for each situation, except for establishing the limit of stability, in which the sequence of movements can be completed before completing this period of time. Each individual had a personalized interval between the tasks, depending on their condition at the end of each one, whether they felt dizzy or not, or asked questions. The patient’s safety, regarding the risk of a possible fall, was ensured by the use of a protector bracket with straps and a safety belt.To determine the limit of stability, the individual was instructed to perform maximal anteroposterior and lateral body displacements using the ankle strategy, without moving the feet or using trunk strategies. The patients moved slowly until they reached their body limit of stability according to the following sequence: 1) forward; 2) return to starting position; 3) to the right; 4) return to starting position; 5) to the left; 6) return to starting position; 7) backward; and 8) return to the starting position. The patients were asked to perform this sequence of movements twice, within the 60 s stipulated for this evaluation.To evaluate the pressure center area and the sway velocity in ten sensory conditions, the patient was instructed to remain still in orthostatic position for 60 s: 1) on firm ground, with open eyes; 2) on firm ground, with closed eyes; 3) on a foam pillow, with closed eyes; 4) on firm ground, with saccadic stimulation; 5) on firm ground, with optokinetic stimulation in the horizontal direction, from left to right; 6) on firm ground, with optokinetic stimulation in the horizontal direction, from right to left; 7) on firm ground, with optokinetic stimulation in the vertical direction, from top to bottom; 8) on firm ground, with optokinetic stimulation in the vertical direction, from the bottom up; 9) on firm ground, with optokinetic stimulation in the horizontal direction, associated with slow and uniform head rotation movements; 10) on firm ground, with optokinetic stimulation in the vertical direction, associated with slow and uniform head flexion and extension movements.th to the 10th conditions, along with a mask, to occlude the lateral view. The individuals were instructed in the fourth condition to follow with their eyes randomized targets with different colors and letters, to stimulate the saccadic system; from the fifth to the eighth conditions, to look at the center of their visual field, at alternating black and white moving bands to induce optokinetic nystagmus; and for the ninth and tenth conditions, to look at the center of their visual field, at alternating black and white moving bars and to perform slow and uniform movements of rotation and flexion-extension of the head with steady shoulders and trunk, to elicit optokinetic nystagmus and vestibuloocular reflex.The virtual reality googles were used in the evaluations from the 4At the end of the evaluation, the platform software provided a worksheet with the values of the limit of stability area, pressure center area, and sway velocity.t-test in the comparison of the groups  according to the gender; Student’s t test for independent samples in the comparison of groups  according to the limit of stability area. The significance level was set at 5% (α = 0.05) in all the conclusions obtained through the inferential analyses. The data were entered into Excel 2010 for Windows spreadsheets for adequate storage of the information. The statistical analyses were performed using the SPSS statistical program SPSS .The statistical analysis of the collected data was initially performed in a descriptive way through the mean, median, minimum and maximum values, standard deviation, absolute and relative frequencies (percentage). The inferential analyses used to confirm or disprove the findings of the descriptive analysis were: Mann–Whitney test in the comparison of the groups  according to age, pressure center area and sway velocity; Fisher's exacBody balance data were collected through the posturography evaluation of the BRU™ of patients with vestibular migraine, referred by the Outpatient Clinic of the Otology and Neurotology Discipline of the Department of Otorhinolaryngology Head and Neck Surgery of Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM).p > 0.999).The selected sample consisted of 56 individuals, 26 (47.16%) in the experimental group, with vestibular migraine in the intercritical period of the disease, and 30 (53.57%) in the control group. The group of patients with vestibular migraine comprised 25 (96.15%) women and 1 (3.85%) man. There was no significant difference between the groups regarding gender (p = 0.544).The experimental group had a mean age of 41.15 ± 15.14 years, ranging from 17 to 68 years, whereas the control group had a mean age of 38.53 ± 16.37 years, ranging from 18 to 72 years. There was no significant difference between the groups in relation to age , with a minimum value of 2 and a maximum value of 10.The group with vestibular migraine had a mean score of 37.07 points as the total score (SD = 18.49) when the DHI quality of life questionnaire was applied, 14.00 points (SD = 6.04) for the physical aspect, 12.75 points (SD = 8.38) for the functional aspect, and 11.50 points (SD = 8.00) for the emotional aspect. All the cases from the two groups completed the evaluation of the ten sensory conditions at the posturography with the BRU™, without moving the feet and upper limbs or falling.p = 0.102) between the values of the limit of stability area (cm2) in the vestibular migraine group and the values obtained in the control group  were observed between the sway velocity values in nine of the ten sensory conditions; there was no significant difference for the unstable surface condition and closed eyes (p = 0.341)  in the experimental group were higher than those in the control group in the ten assessed conditions. When comparing the experimental and the control groups, statistically significant differences (= 0.341) .Figure 22) in the experimental group were higher than those of the control group in the ten assessed conditions. There was a significant difference (p < 0.05) between the values of the pressure center displacement area in eight of the ten sensory conditions; no significant difference was found for the condition unstable surface and closed eyes (p = 0.139) and for the condition on firm ground and saccadic stimulation (p = 0.066)  .Figure 3The static posturography integrated to visual stimuli of the BRU™ virtual reality system evaluated the body balance of patients in the intercritical period of vestibular migraine in comparison to a group of healthy individuals. In vestibular disorders and healthy young and elderly individuals, the reliability and validity of pressure center measurements obtained during the evaluation of the sensory integration processes were demonstrated using the BRU™, showing clinical validity and efficacy similar to those of the SMART EquiTestTM sensory organization test .The groups were homogeneous in relation to age and gender, with a predominance of females. Vestibular migraine occurs more frequently in women, at any age group,The influence of the symptoms was classified as mildDuring the static posturography assessment using the BRU™, the limit of the stability area, similar in the patients during the intercritical period of vestibular migraine and in the control group, showed the preservation of the capacity to safely move the body to the maximum in the anteroposterior and latero-lateral direction on the pressure center without changing the support base.At the static posturography with the BRU™ in vestibular migraine, in comparison with the control group, the increase in the sway velocity in nine of the ten conditions and in the pressure center displacement area in eight conditions demonstrated the objective postural instability of the patients with vestibular migraine, even in the intercritical period of the disorder, suggesting the influence of the vision, proprioception, visual stimuli and vestibulovisual interaction on postural control and identified impairments in the ability to effectively use vestibular, visual and somatosensory information.The increase in the sway velocity and/or the pressure center displacement area in vestibular migraine was observed under conditions 1, 2, 5, 6, 7, 8, 9 and 10. Condition 1, on firm ground with open eyes, indicated that the use of visual and somatosensory cues was insufficient to compensate for the inaccurate vestibular system information. Condition 2, on firm ground and closed eyes, indicated that the somatosensory and vestibular cues were not sufficient without the visual ones. Conditions 5–8, on firm ground and optokinetic stimulation to the right, to the left, upward and downward, showed the inability to suppress the influence of the optokinetic visual information and rely on proprioceptive and vestibular stimuli, characterizing visual dependence.The patients with vestibular migraine assessed by the BRU™ showed similar performance at the sway velocity and the pressure center displacement area control in Condition 3, on unstable surface and closed eyes, the most challenging of the conditions, in which the somatosensory cue is imprecise on the foam pillow and visual information is absent, and the vestibular system is the main source of sensory information to maintain postural control.The difficulty in standing upright with eyes closed on an unstable surface was also identified in 31.8% of individuals aged 40 years or older without a history of dizzinessThe patients with vestibular migraine assessed at the BRU™ showed, in Condition 4, on firm ground and saccadic stimulation, a pressure center displacement area similar to that of the control group; the lower body sway during exposure to saccadic stimulation would facilitate the control of ocular movements and target visualization.Therefore, considering these findings, the patterns identified in the group of patients with vestibular migraine included in this study corresponded to: vestibular dysfunction (Condition 1), vestibular and somatosensory dysfunction with visual dependence  and vestibulovisual dysfunction (9 and 10).It is difficult to compare the findings in the intercritical period of vestibular migraine in the virtual reality posturography using the BRU™ with those of other types of posturography that use different technologies, protocols and evaluation parameters. However, results from other types of posturography related to the capacity to maintain postural control also show the increased sway in some sensory conditions in vestibular migraine, suggesting the difficulty to use vestibular information with or without somatosensory and/or visual dependence.15The pressure center displacement area and sway velocity increased at the BRU™, showing worse postural control with and without visual deprivation, due to visual conflict and vestibulovisual interaction, suggesting that functional alterations may persist even in the asymptomatic intercritical period of the vestibular migraine, similarly to what occurs in other vestibular disorders, such as Meniere's disease and Benign Paroxysmal Positional Vertigo (BPPV). In Menière’s diseaseThe identification of significant findings in the intercritical period of vestibular migraine, when compared to healthy subjects, showed the clinical applicability of posturography integrated to the virtual reality of the BRU™ system, recreating environmental stimuli and situations capable of measuring postural responses to different sensory conditions, sensitizing the semiological exploration and disclosing relevant information on body balance.The characterization of the postural control disorder, even during the interval between vertiginous episodes, can provide valuable data on the patient's functional capacity, assisting in the early diagnosis, prevention of the potential occurrence of symptoms resulting from dysfunction signs identified before the clinical episode, and in the creation of personalized protocols of vestibular rehabilitation exercises. New experiments will be useful to continue investigating postural control in vestibular migraine and to confirm the findings of this research.Posturography with virtual reality can identify changes in the sway velocity and the pressure center displacement area, characterizing the inability to maintain postural control with and without visual deprivation, in situations of visual conflict and vestibulovisual interaction, in the intercritical period of vestibular migraine.The authors declare no conflicts of interest.


We observed that both early and subsequent epidemic characteristics contribute to the pre-delta epidemic size of COVID-19. This identification is important to the prediction of the emerging viral infectious diseases in the primary stage.It is still uncertain how the epidemic characteristics of COVID-19 in its early phase and subsequent waves contributed to the pre-delta epidemic size in the United States. We identified the early and subsequent characteristics of the COVID-19 epidemic and the correlation between these characteristics and the pre-delta epidemic size. Most (96.1% (49/51)) of the states entered a fast-growing phase before the accumulative number of cases reached (30). The days required for the number of confirmed cases to increase from 30 to 100 was 5.6 (5.1–6.1) days. As of 31 March 2021, all 51 states experienced at least 2 waves of COVID-19 outbreaks, 23.5% (12/51) experienced 3 waves, and 15.7% (8/51) experienced 4 waves, the epidemic size of COVID-19 was 19,275–3,669,048 cases across the states. The pre-delta epidemic size was significantly correlated with the duration from 30 to 100 cases ( Coronavirus 19 disease (COVID-19) has led to a worldwide pandemic . As of 3After experiencing the early small-scale spread of the COVID-19 epidemic, many areas in the United States still experienced multiple outbreaks and spatiotemporal changes despite the government’s interventions, such as repeated lockdowns and the wide use of face masks ,11,12. PVarious mathematical methods have been used to describe and predict the trend of the COVID-19 epidemic in the United States ,17,18,19We hypothesized that the severity of the COVID-19 epidemic could be characterized by epidemiological indicators in the early stage and subsequent waves of the epidemic. To address this question, we collected publicly available COVID-19 epidemic data from 51 states  in the United States. We also conducted the correlation analysis after identifying the epidemic characteristics by the Joinpoint software and multi-logistic fitting. As the high vaccine coverage and delta variant represent different transmission patterns, we limit our data collection and analysis to 31 March 2021. This study aims to identify the impact of the epidemic characteristics in the early stage and subsequent waves on the pre-delta epidemic size in 51 states of the US.The geographic distribution of the COVID-19 epidemic showed a substantial change from 31 March 2020 to 31 March 2021, with a significant shift from the Eastern United States to the Central United States . On 31 MRemarkably, most of the states that experienced three or four waves were concentrated in the central part of the United States. The Getis–Ord Gi* statistic for total COVID-19 infectious identified Eastern United States as COVID hotspots in early 2020 and the Central United States as hotspots in 2021 and late 2020 . The AnsWe demonstrated two-phase linear fits to the first 100 confirmed cases of COVID-19 during the early phase of the epidemic in the 51 states of the US . The simp = 0.003, r = −0.405) and growth rate of the fast-growing phase . Additionally, epidemic size also showed significant positive correlations with K1 , K2 , K3  and K4 . In addition, the epidemic size was positively correlated with the new cases on restriction day  and new cases on reopening day .As of 31 March 2021, the overall epidemic size was 30,326,324 cases in the United States, ranging from the lowest 19,275 cases in Vermont to 3,669,048 cases in California. 1 , K2 , and K3 . There is a negative correlation between HAQ and Δt1  and Δt4 . In contrast, the new cases on reopening day showed a positive correlation with K1 , K2 , K3 , and K4 .Notably, early characteristics of the epidemic also show a correlation with overall epidemic-wide fluctuations . Time frOur study demonstrated that during the early phase of the epidemics in 51 US states, 30 cases appear to be a critical threshold for switching from a relatively slow-growing phase to a fast-growing phase. This is consistent with one of our previous published studies . We idenOur study demonstrated similar early epidemic characteristics in the US compared with the previous findings in China . In bothOur study indicated that early characteristics are predictive of the subsequent waves of the epidemics and the epidemic size. Notably, the shorter the duration to increase from 30 to 100 cases in its early phase, the more severe the subsequent epidemic burden. The shorter duration represents a more rapid epidemic spread and likely reflects the absence of effective prevention strategies and diagnostic capacity in the states, leading to a high transmission rate. Consistent with this, more rapid growth in the early phase is also associated with a greater magnitude of subsequent waves. We believe the early rapid development of the outbreak may serve as an important warning signal for the healthcare system to respond to the outbreak and help predict the potential size of COVID-19 in the later development of the epidemic.Our study demonstrated a significant shift in the geographical distribution of the COVID-19 epidemic from coastal to inland states, and inland states appeared to have experienced more subsequent waves, similar to the results of an earlier study . This miOur study also demonstrated a strong correlation between waves. We are the first to identify the number of waves and quantify the size and duration of the waves. We report the subsequent waves were at least three times more than the first waves and each cycle of the waves is about 3 months. The duration likely reflects the time for the healthcare system to react, intervene, and gradually reduce the epidemics.There are some limitations to our findings. First, our research only verified the pre-delta epidemic data before 31 March 2021 without considering the underestimated cases in the first waves  and the We collected publicly available data from 51 states in the United States, that reported on cases of COVID-19  from 21 January 2020 to 31 March 2021 from the Coronavirus resource center of Johns Hopkins University and Medicine , for somWe collected social distancing data from the IHME COVID-19 Forecasting Team’s article . We alsoWe defined the epidemic size for each state as the cumulative number of confirmed cases on 31 March 2021.For the early epidemic trend of each 51 states, we used the Joinpoint software  to identWe also collected various non-pharmacological intervention indicators under the epidemic situation, which were as follows: (1) the time of first restriction and first reopening for 51 US states; (2) the confirmed new cases on the day of restriction and reopening.https://logletlab.com/, accessed on 5 April 2022) to identify the key characteristics of the COVID-19 epidemic based on the cumulative number of confirmed COVID-19 cases. We modelled the epidemic patterns by identifying 1 to 4 growth waves of the COVID-19 epidemic. We identified: (1) Km  for each wave which represents the asymptotic values that bound the function and therefore specify the level at which the epidemic saturates. The sum of K represents the point at which the epidemic has finally reached saturation; (2) tm for each wave represents the midpoint of each epidemic growth and hence the peak of each outbreak. tm4-tm3, tm3-tm2, tm2-tm1 represent the time interval between the two consecutive outbreaks. The sum of tm represents the sum of the time required for each epidemic to reach its peak; (3) Δt for each phase represents the lengths of time intervals required for the epidemics to grow from 10% to 90% of the saturation level. The sum of Δt represents the sum of the interval lengths required for each epidemic to increase from 10% of saturation level to 90%. m, tm and Δt.For the study period in each of the 51 states, we used a simple multi-logistic fitting . The reported incidence in each state was joined to the shapefile of state boundary by administrative unit code. We created distribution maps for the COVID-19 on 31 March 2020, 11 December 2020 (the day when the Food and Drug Administration (FDA) of the United States issued an Emergency Use Authorization (EUA) for the first vaccine to prevent COVID-19) , and 31 1, K2, K3, K4, Sum of K; tm1, tm2, tm3, tm4, sum of tm; tm4-tm3, tm3-tm2, tm2-tm1; Δt1, Δt2, Δt3 Δt4, Sum of Δt).After verifying the non-normal distribution of most variables through the Kolmogorov–Smirnov test, we used the Spearman correlation test in the OriginPro 2021b software  to examine the correlation between epidemic size, early epidemic characteristics , fast-growing phase (case/day)), intervention  and HAQ indicators and the multi-logistic fitting characteristics of the subsequent epidemics ).We also compared the differences among KIn conclusion, we confirmed that the first 30 cases of COVID-19 might be a critical threshold for switching from a relatively slow-growing phase to a fast-growing phase in the early epidemic in the United States. Further, most states have experienced more than 1 wave of the COVID-19 epidemic, and the magnitude of the first wave tends to predict the magnitude of subsequent waves. The pre-delta epidemic size is negatively and significantly correlated with the duration from 30 to 100 cases but positively correlated with the growth rate of the fast-growing phase, and the peak cases in the subsequent 4 waves.


This paper analyzes the kinematics and applied forces of pregnant and non-pregnant women dummies sitting in the rear seat during a frontal vehicle collision to determine differences in the features of abdominal injuries. Sled tests were conducted at 29 and 48 km/h with pregnant and non-pregnant dummies . The overall kinematics of the dummy, resultant acceleration at the chest, transrational acceleration along each axis at the pelvis, and loads of the lap belt and shoulder belt were examined. The belt loads were higher for the MAMA IIB than for the Hybrid III because the MAMA IIB had a higher body mass than the Hybrid III. The differences in the lap belt loads were 1119 N at 29 km/h and 1981–2365 N at 48 km/h. Therefore, for restrained pregnant women sitting in the rear seat, stronger forces may apply to the lower abdomen during a high-velocity frontal collision. Our results suggest that for restrained pregnant women sitting in the rear seat, the severity of abdominal injuries and the risk of a negative fetal outcome depend on the collision velocity. Trauma is common among pregnant women, with 1 in 12 pregnancies affected . It has Injuries sustained during pregnancy, when the lower abdomen protrudes according to the gestational age, have been considered different from those sustained before pregnancy. Several reports have suggested differences between pregnant and non-pregnant women in the type and severity of abdominal injuries due to the fact of MVCs. A retrospective analysis using data from the NASS/CDS database compared the injury severity between pregnant and non-pregnant women. This comparison was made for 1059 pregnant women and 34,439 non-pregnant women, and the backgrounds of the collisions were similar between the two groups. The study concluded that the risk of an abbreviated injury severity (AIS) score of two or more (AIS 2+) for injury to the abdomen was similar in the two groups . HoweverThe use of a mechanical model with high human similarity is appropriate to determine the kinematics of vehicle passengers. Although various types of dummies have been used in officially recognized automotive accreditation tests, only one pregnant woman dummy has been used  . StudiesThe most recent version of the MAMA IIB, which was developed by First Technology Safety Systems and the University of Michigan Transportation Research Institute in 2001, was used . This duIn each test, the dummy was seated on the right side of the rear seat wearing a three-point seatbelt. The seat corresponded to a sedan type of mid-size car with a reclined torso angle of 20°. To represent situations of the frontal impact of a passenger vehicle, trapezoid waveforms measured in a flat barrier test with vector velocity changes at the time of impact (delta-V) of 29 and 48 km/h were applied to the sled.One test using the MAMA IIB (test 1) and one test using the Hybrid III (test 2) were performed at a delta-V of 29 km/h. One test using the MAMAIIB (test 3) and two tests using the Hybrid III (tests 4 and 5) were performed at a delta-V of 48 km/h. The airbag and seatbelt pretensioner were not activated at any time throughout the tests. The overall kinematics of the dummy, such as trajectory during impact, were examined through high-speed video imaging. An accelerometer and load cell mounted on the dummy measured the resultant acceleration at the chest, transrational acceleration along each axis at the pelvis, and the loads of the lap belt and shoulder belt. Additionally, in the sled tests, forward displacement of the pelvis was measured. For comparison, the resultant acceleration was calculated as the square root of the sum of squares of each axial component of acceleration.In the test using the MAMA IIB at a delta-V of 48 km/h (test 3), the dummy moved forward by 165.2 mm at 67 ms, and in the test using the Hybrid III at a delta-V of 48 km/h (tests 4 and 5), the dummy moved forward by 151.1 and 151.4 mm at 67 ms. According to tests 3 and 4, both dummies at 67 ms from initial impact are shown in 2 at 67.1 ms from the initiation of impact in test 1 and 278.3 m/s2 at 65.8 ms in test 2.2 at 59.6 ms, 471.1 m/s2 at 55.7 ms, and 478.1 m/s2 at 55.6 ms, and the curves of the acceleration were similar.2) than for the Hybrid III (275.7 m/s2). At a delta-V of 48 km/h, the acceleration rose more rapidly for the Hybrid III (tests 4 and 5) than for the MAMA IIB (test 3). The maximum acceleration was higher for the MAMA IIB (500.4 m/s2) than for the Hybrid III (416.6 m/s2 in test 4 and 415.1 m/s2 in test 5).Time courses of the longitudinal accelerations of the pelvis are shown in Time courses of the lap belt load are shown in Time courses of the shoulder belt load are shown in In this study, we confirmed the kinematics and applied forces for pregnant and non-pregnant women sitting in the rear seat of a vehicle during a collision.There was little difference in the distance moved forward between the MAMA IIB and Hybrid III at both 29 and 48 km/h for similar occupant restraint conditions. Therefore, for pregnant women, an effect of the seatbelt restriction similar to that for non-pregnant women was obtained. This result emphasizes the importance of correct seatbelt use for pregnant women. In 2001, before the legal enforcement of seatbelt use in the rear seat, the majority of pregnant women vehicle passengers (80.9%) never used a seatbelt in the rear seat in Japan . After tThe results of the present study showed higher belt loads for the MAMA IIB than for the Hybrid III. The difference in the lap belt loads was approximately 1 kN at 29 km/h and approximately 2 kN at 48 km/h. These results were due to the difference in the dummies’ mass, with the MAMA IIB being 9 kg more massive than the Hybrid III. Additionally, the belt load increased more rapidly for the Hybrid III than for the MAMA IIB at both velocities. It is considered that the initial restraint of the lap belt was simply delayed for the MAMA IIB compared with the Hybrid III because of the difference in the shape of the abdomen, in that the lap belt was fitted to the lower abdomen of the non-pregnant dummy in contrast with the case for the pregnant dummy. However, as the distances of forward movement were similar for the two dummies in our study, the delay of the initial restraint of the lap belt for the MAMA IIB would be trivial.In this study, the differences in the lap belt loads increased with the collision velocity. Therefore, for pregnant women sitting in rear seats, the lower abdomen may be subjected to stronger forces when there is a frontal collision at high vehicle velocity. A risk curve for an adverse fetal outcome based on real-world collisions involving pregnant women reveals that, even if using a seatbelt adequately, the risk increases with collision velocity in that the risk of an adverse fetal outcome exceeds 60% when the collision velocity exceeds 48 km/h . This trThere are different results for the injury severity of the abdomen in the literature in that the risk of AIS 2+ injury has been shown to be higher, similar, or lower in pregnant women than in non-pregnant women ,12,13. OIn this study, similar values for the acceleration of the chest were obtained for the two dummies. However, because the MAMA IIB had a greater body mass than the Hybrid III, shoulder belt loads were higher for the MAMA IIB than for the Hybrid III . A previous study reconstructing a frontal vehicle collision using the MAMA IIB for the driver suggested that there was a shoulder belt load of 4.6 kN at a collision velocity of 40 km/h with the deployment of an airbag and activation of a pretensioner and force limiter . Our resThere are limitations to the present study. First, because the pregnant dummy used in this study represented 30 weeks of gestation, the obtained forces and kinematics were limited to pregnant women at approximately 30 weeks of gestation. Therefore, the results may not apply to all gestational ages of pregnant women.Second, we performed the sled test only once or twice for each condition. However, because the sled test is a physical test using a mechanical dummy, reliable results can be obtained in a single run. In fact, an officially recognized automotive accreditation test is based on a single collision test. We therefore believe that the results of the present study are sound.Third, we used an interior buck representing a single sedan-type vehicle in this study. The geometry of the driver’s seat does not differ appreciably among sedans, regardless of the original equipment manufacturer or class of car. However, we understand that sport utility vehicles have a different geometry from sedans with more upright sitting positions, likely resulting in different outcomes.We analyzed the kinematics and applied forces of pregnant and non-pregnant women dummies sitting in the rear seat during a frontal vehicle collision. The two dummies had similar kinematics with similar forward movement in the collision. The belt loads were higher for the MAMA IIB than for the Hybrid III, because the MAMA IIB had a higher body mass than the Hybrid III. The difference in the lap belt loads were 1119 N at 29 km/h and 1981–2365 N at 48 km/h. Therefore, for restrained pregnant women with a gestational age of approximately 30 weeks sitting in the rear seat, stronger forces may apply to the lower abdomen at a higher velocity of frontal collision. Our results suggest that for restrained pregnant women sitting in the rear seat, the severity of abdominal injury and the risk of a negative fetal outcome may depend on the collision velocity. A driver should not drive at an excessive velocity when a restrained pregnant woman is sitting in the rear seat.


Study. A group of 30 patients with allergic bronchial asthma (BA) were investigated in our study. All of the patients were tested for the presence of SIBO by the SCFA spectrum determination. For the SIBO treatment, 10 patients from the studied group were prescribed Rifaximinum with the 200 mg dose at 3 times a day for a week; the other 10 patients were prescribed Rifaximinum at the same dose, followed by the administration of the Lactobalance probiotic in capsules at 3 times a day for a month. A month probiotic course was assigned to the remaining 10 patients without SIBO, as part of the BA complex therapy. The SCFA studies were immediately carried out for all of the patients after the 1 month probiotic therapy course.  It was established that the high biological diversity of intestinal microorganisms promotes the needed SCFAs production, which induces immune regulatory pathways and contributes to the anti-inflammatory response. p < 0.001), acetic and butyric acid (p < 0.001) had increased. The Rifaximinum course, followed by administration of the probiotics led to a decrease of the relative amount of isoacids and ratio of isoacids/acids in the studied patients as compared to the patients who had received Rifaximinum for the SIBO treatment only (p < 0.05).  A normalization of the SCFA spectrum and anaerobic index for all of the studied patients were noted. Upon taking the probiotics, it was revealed in the patients without SIBO that the total content of fatty acids ( The obtained results demonstrate a potential opportunity of the drug influence on the active bacterial metabolites composition and amount in the intestinal biotope; as it was confirmed by the restoration of the intestinal microbiocenosis and microorganism habitat. The gastrointestinal tract contains a large, complex, and dynamic population of microorganisms which have noticeable influence on human health –4. The rShort-chain fatty acids (SCFAs) have the greatest functional importance in the entire spectrum of bacterial metabolites  –9. In moThe gut microbiota composition change or/and low biological diversity of microorganisms were associated with the SCFAs formation decrease. In turn, it has led to a polarization of the immune response towards type 2 T-helpers and formation of proinflammatory reactions, as it was shown in the experimental and clinical studies , 8–13.The molecular mechanisms, which help SCFAs to reduce Th-2 mediated immune responses, are constantly being refined. A possibility of the SCFA influence on the activity of nuclear transcription factor, tumor necrosis factor-alpha and interaction with antigenic recognition receptors, G-protein receptors of polymorphonuclear neutrophils, etc. have also been established , 8, 9.The SCFAs amount and ratio can reflect not only the composition of the intestinal biotope but also the functional activity of the bacterial representatives present , 12, 13.The aim of the research was to study the possibilities of correcting the short-chain fatty acids (SCFA) content and profiles in feces of the patients with allergic bronchial asthma.This prospective, randomized, controlled study was approved by the Local Ethics Committee of the Sechenov First Moscow State Medical University, Russian Federation (Protocol No. 05-18) on May 16, 2018 and was conducted in accordance with the Declaration of Helsinki. The aim of the study was explained to the potential participants and the signed consents were obtained from the patients before their enrolment in the study.Between June 2018 and October 2018, we enrolled 30 patients with acute exacerbation of allergic bronchial asthma  with the average age of 37.7 ± 10.1 years and anamnesis duration of 11.4 ± 8.7 years . All patAll of the patients were additionally tested using a hydrogen breath test with lactulose for the presence of the syndrome of intensive bacterial overgrowth (SIBO) in the small intestine. According to the obtained results of the test, 20 patients with a positive test for SIBO were randomly divided into 2 groups (10 people each group). The randomization process was performed using a computer-generated randomization table. The remaining 10 patients with a negative test for SIBO were assigned to the third group.9 CFU/capsule at least): there were Lactobacillus gassery KS-13, Lactobacillus gasser LAC-343, Lactobacillus ramnosus LCS-742, Bifidobacterium bifidum G9-1, Bifidobacterium longum MM-236, Bifidobacterium longum MM-236 M, Bifidobacterium infantis M-63, Bifidobacterium breve M16V type T, and Bifidobacterium lactis B1-04 in the capsule. The third group was consisted of the 10 patients with allergic asthma without detected SIBO (SIBO (-)) and they took the Lactobalance probiotic, as it was part of a standard therapy for the BA treatment in the group. The control group included 17 healthy volunteers . All of the studied groups were comparable among themselves by age (p > 0.05) and gender (p > 0.05). The patient groups were comparable in terms of anamnesis (p > 0.05) and disease severity (p > 0.05).The first group was consisted of the 10 patients with a positive test for SIBO (SIBO (+)) and was prescribed Rifaximinum of 200 mg dose, 3 times a day for a week together with a standard BA treatment. The second group was consisted of the 10 patients with a positive test for SIBO (SIBO (+)) also, but they took Rifaximinum of 200 mg dose, 3 times a day for a week together with the prescription of Lactobalance probiotic. The Lactobalance probiotic was prescribed in capsules, to be taken 3 times a day for a month, where each capsule had contained three billions of probiotic microorganisms .To diagnose the syndrome of intensive bacterial overgrowth (SIBO) in the small intestine, a hydrogen breath test with lactulose Gastrolyzer (Bedfont Scientific Ltd) was performed.2), propionic (C3), and butyric (C4) acids, the level of isoacids, and the ratio of isoacids to acids (isoCn/Cn) as well as the values of the anaerobic index (AI = (C3 + C4)/C2) were evaluated [The SCFA spectrum was determined by gas-liquid chromatographic analysis. The study was carried out on the “Chromos GH-1000” gas chromatograph with a flame ionization detector. The absolute and relative contents of acetic .p < 0.001) as well as the absolute concentrations of acetic, propionic, and butyric acids (p < 0.001) in patients with BA (regardless of the disease phenotype) were found. The altered spectrum of SCFA was revealed: anaerobic metabolism of microflora was determined for 84% of the patients, and aerobic metabolism of microflora was determined for 16% of the studied patients. The values of the anaerobic index varied in accordance with the metabolic profile of SCFA. A sharp shift of the index towards negative values for the anaerobic type (p < 0.01) and to the zone of opposite values for the aerobic type [At the first stage of the investigation, we have studied the level and spectrum of SCFA in feces of the patients with allergic and nonallergic BA and a group of healthy volunteers. The results of that study were published in the Journal Clinics and Practice 2019, No. 9. A significant decrease in the total content of SCFA . The level of the remaining SCFAs as well as the total content of ones did not change after the treatment in these groups .Patients of the third group (SIBO (-)), which were not needed to prescribe an antibacterial drug, a significant increase of the total content was revealed for SCFAs, acetic, and butyric acids. A decrease of the isoacids amount was also noted .We had been determining the spectrum of SCFA during the study. After the aimed therapy for the microbiota correcting of the intestinal biotope, the ratio of SCFA to acetic : propionic : butyric was indistinguishable in all of the studied patients from the control group . Those rp < 0.001) and group of the patients who had taken Rifaximinum only (p < 0.05). The decrease of these indicators was also detected for the patients who had been taking Lactobalance only, as it was also confirmed by the preepithelial and epithelial levels improvement of intestine in a response to the probiotic therapy. The treatment used also contributed to a normalization of the anaerobic index values in all the studied groups (p > 0.05)  .A commensal microbiota constantly interacts with the immune system training immune cells to respond to antigens , 2, 7. MIt was established that the high biological diversity of intestinal microorganisms promotes the needed SCFAs production, which induces immune regulatory pathways and contributes to the anti-inflammatory response –9. On thAs mentioned earlier, the SCFA's change indicates on the microbiocenosis violations of the intestinal biotope in the patients with BA , 9, 11. The result of the presented study is the revealed changes in the synthesis of SCFAs during the BA treatment with SIBO in the two schemes (antibiotic and antibiotic + probiotic), as well as against the background of the probiotic preparation prescription for the patients without SIBO.p < 0.05). Similar changes (p < 0.001) were also obtained in the patients who had taken a probiotic preparation as part of the BA complex therapy. The obtained results reflect the positive effect of probiotic cultures on the state of the intestinal mucosa and indicate the restoration of the preepithelial and epithelial layers in general, and the composition of the microbiota with proteolytic activity has been normalized also [The consumption of probiotic Lactobalance after a course of Rifaximinum led to a decrease in the relative amount of isoacids and the ratio of isoacids/acids in comparison with patients who received Rifaximinum only for treatment of SIBO , acetic, and butyric acid (p < 0.001) was revealed for a short observation period, which demonstrated the positive effect of the probiotic Lactobalance preparation on the activation of endogenous flora and normalization of its metabolic activity.In patients of the third group, who received the probiotic as a part of the complex BA therapy, a significant increase of the SCFA total content (p > 0.05).In all patients, after the treatment had been aimed to modify the intestinal microbiota composition, the SCFA spectrum and values of the anaerobic index were similar to the consequent values for the control group (Thus, our results demonstrate the potential possibility for the drug exposure on the composition and active bacterial metabolites amount in the intestinal biotope. The presented results indicate that further study of the intestinal microbiota changes will be needed with regards to BA disease. Obviously, to achieve the reference values of the SCFA amount, a more durable period of the probiotic therapy will be needed for that. So far, we cannot answer the following questions: would the SCFA amount and spectrum change if the patients with BA and SIBО have been prescribed a probiotic drug only? Does the microflora correction influence the asthma course? It will be evaluated in a result from the further monitoring of these patients.


On the other hand, a slightly lower final weight (p > 0.05) in the group supplemented with humic substances was found compared to the control group. In the comparison of the individual parameters of the meat quality in rabbits, we observed a positive effect in the reduction in the intramuscular fat content and the lipid parameters as well as a lower total cholesterol from the blood serum in both supplemented groups. Regarding the mineral parameters, we observed elevated blood serum values of calcium and phosphorus in both experimental groups. The addition of humic–fatty substances appears to be the most effective way of supplementing rabbit feed due to the synergistic effect of humates and vegetable oils for their optimal growth development and the production of reduced-fat meat.In this study, we assessed the effect of humic substances, as an organic supplement in feed, on the fattening performance, meat quality and selected lipid and mineral parameters from the blood serum of rabbits. Three groups of the Giant Saris rabbit breed were used , with 16 animals per group. The animals in the control group were fed a standard pellet diet, the humic substances group received a basal diet supplemented with 5% humic substances, and the third group received a basal diet with 5% humic–fatty substances preparation during the entire experiment (from 35 to 120 days of age). There were 85 days of fattening; then, the rabbits were slaughtered. In the group supplemented with 5% humic–fatty substances addition, we noticed a higher final weight ( Livestock farming for meat production is one of the main sectors of livestock production. In addition to traditional species such as pig, cattle, and poultry, this industry is developing by farming new species such as rabbits . RabbitsIn order to improve the immunity and production characteristics of livestock, in recent years, feed mixtures have started to be enriched with various additives, helped by several legislative changes in Europe, linked to the elimination of the use of antibiotics, growth promoters, and other chemical preparations in livestock nutrition . One posThe aim of this work was to compare the impact of the addition of two products based on humic substances (HS) and humic–fatty substances (HFS) in a granular compound feed on the fattening performance, quality of meat, and selected biochemical parameters in rabbit blood serum.The rabbits were bred under the same conditions in an air-conditioned hall in standard cages for rabbit breeding (80 × 40 × 66 cm); in each cage, there were four rabbits. During the experiment, light was provided for 16 h, with 8 h of darkness. The average temperature in the hall was 22 ± 4 °C, and the relative humidity was 70 ± 5%. The experiment was performed after approval from the Ethics Commission of the University of Veterinary Medicine and Pharmacy in Košice .The study included 48 rabbits of the Saris giant rabbit breed of both sexes at the age of 35 days, divided into three groups, namely a control group without the addition of HS and two groups with 5% addition of HS or HFS. The selection of rabbits into groups was random; sixteen rabbits were selected for each group, and each group consisted of 4 replicates, with four rabbits within each replicate.The control group was given a pellet basal diet for growing rabbits without any supplements, according to the recommendations given in the international feeding standards , contain® Natur AFM; 65% HS share in the dry matter) during the entire fattening period (from 35 to 120 days of age). The second experimental group was given a basal diet with 5% addition of a humic–fatty substances preparation  composed of 80% humic-mineral carrier, and 20% vegetable oils .The first experimental group was administered a pellet basal diet with 5% addition of humic substances . The yield of the carcass was determined as the ratio of the final body weight at 120 days of fattening to the carcass weight.Throughout the research period (85 days), the animals were fed the granular mixtures ad libitum and had free access to drinking water. The weight of the rabbits was determined by weighing at the ages of 35, 60, 90, and 120 days. At the end of the experiment, after 12 weeks of HS and HFS administration, at 120 days of age, 6 male rabbits from each group were randomly selected for blood and meat collection. The selected rabbits were killed by electric stunning  with a minimum current of 0.3 A and a voltage of 110 V, with subsequent cutting through the musculus longissimus dorsi). The meat sample was collected 1 h after slaughter, wrapped in foil, and stored at 4 °C for 24 h until quality analysis. The pH of the meat samples was analyzed with a digital InoLab pH meter . The water content was determined by oven-drying at 105 °C [Blood samples were collected in tubes and centrifuged for 15 min to obtain blood serum at 1180 g. The chemical analysis of the basic components of meat was evaluated from dorsal muscle samples , triglycerides (TG), and concentrations of HDL (high density lipoprotein) and LDL (low density lipoprotein) were determined from the blood serum, according to the methods in Hammand et al. . Calciump < 0.05. The significance of the differences between the different growth rates, meat quality, and biochemical parameters was confirmed by means of Tukey’s multiple comparison test. This test was applied to find the means that were significantly different from each other between the monitored groups. The results in the tables are given as the average value (X) and the mean standard deviation (SD).The measured values were evaluated by one-factor analysis of variance (ANOVA) with the level of significance set at −1 in the HFS supplemented group, compared to the control (31.1 g·d−1) and HS groups (3.08 g·d−1) at the end of the fattening period, at the age of 120 days. Moreover, the higher weight in the HFS group at 85 days of fattening had a positive effect on the increased carcass weight and yield after slaughtering. On the other hand, in the group of rabbits with pure 5% HS addition, there were slightly lower daily weight gains, which was reflected in the lower weight (p > 0.05) at the end of the fattening period. As in our study, Mista et al.  reportedThe slightly decreased body weight and intramuscular fat in the meat in the HS group may be due to the increased fat metabolism from the beneficial detoxifying effects of the humic substances on the liver. Due to the increased fat metabolism, lower blood cholesterol levels were observed in both supplemented groups compared to the control group. In addition to lower cholesterol, decreased levels of LDL-cholesterol and triglycerides in blood serum were confirmed in the HS group . Mista ep < 0.05) in calcium and phosphorus in the blood serum of both supplemented groups of rabbits  of Ca and P in the blood serum of both supplemented groups. These results make it possible to assume that the administration of humic–fatty substances in rabbit nutrition would improve meat quality indicators and biochemical parameters in the blood due to their synergistic effect. A positive effect can be assumed mainly with the reduction in the fat and cholesterol levels and with the increase in the serum concentrations of essential trace elements, especially Ca and P.Based on the synergistic effect of humic substances and vegetable oils, there was a higher final weight and carcass yield in the group of rabbits supplemented with a 5% addition of HFS in the feed during 85 days of fattening. In addition, supplementation with HS or HFS positively affected the lipid and mineral parameters, which was manifested by lower total cholesterol as well as increased levels (


The purpose of this study was to provide an immuno-mediated substantiation of the etiopathogenesis of mucositis and peri-implantitis based on the results of experimental, laboratory and clinical studies. The biopsy material was studied to identify impregnated nanoscale and microscale particles in the structure of pathological tissues by using X-ray microtomography and X-ray fluorescence analyses. Electron microscopy with energy-dispersive analysis identified the composition of supernatants containing nanoscale metal particles obtained from the surfaces of dental implants. The parameters of the nanoscale particles were determined by dynamic light scattering. Flow cytometry was used to study the effect of nanoscale particles on the ability to induce the activation and apoptosis of immunocompetent cells depending on the particles’ concentrations during cultivation with the monocytic cell line THP-1 with the addition of inductors. An analysis of the laboratory results suggested the presence of dose-dependent activation, as well as early and late apoptosis of the immunocompetent cells. Activation and early and late apoptosis of a monocytic cell line when THP-1 was co-cultured with nanoscale metal particles in supernatants were shown for the first time. When human venous blood plasma was added, both activation and early and late apoptosis had a dose-dependent effect and differed from those of the control groups. It is well known that mucositis and peri-implantitis are complications of dental implantations that are associated with the development of a chronic inflammatory destructive process in the soft and bony tissues of the jaw. Initially, the causes of their occurrence were considered from the perspective of an interaction between the human body and a single certified medical device with a patented surface treatment, without taking the possibility of the emission of particles of different sizes into account.It is known from the literature that the cause of mucositis and peri-implantitis can include titanium ions and nanoparticles as degradation products of medical products under conditions of functional load ,7,8,9,10Previously, the authors of this article suggested that nanoscale metal particles (NSMP) in high concentrations were the main trigger for chronic immunopathological inflammation in the bone bed and oral mucosa tissues. Their accumulation in tissues up to the critical mass called the critical dose of nanoscale metal particles (CDNanoMP) leads to the early death of cells of the innate immune system, which is obviously the main reason for the coagulation of the accumulated nanoparticles with the formation of micron-sized complexes against the background of chronic immunopathological inflammation. The current immunological concept involves the osseointegration and disintegration of dental implants. In our earlier studies ,14,15,16During the second orthopedic stage in the classical technique of dental implantation, the appearance of a functional load facilitates the release of nanoparticles and the formation of microparticles . PresumaThe aim of these multidisciplinary studies was to investigate the influence of nano- and microscale particles on the formation of the conditions for the pathological inflammatory process in tissues. For this purpose, the following methods were used: X-ray microtomography, X-ray fluorescence analysis, electron microscopy, dynamic light scattering and flow cytometry. The possibility of the activation and apoptosis of immunocompetent cells, such as monocytes, was studied in an experimental model. Co-culture of human monocytic leukemia cells (the THP-1 cell line) with NSMP obtained from the surfaces of dental implants made it possible to assess the viability of immunocompetent cells. The use of flow cytometry made it possible to assess the probability of an interaction between immunocompetent cells and the titanium alloy, which was previously considered to be “bioinert”, and to identify the effects of the interaction with certified medical products.A histological study of the soft tissue samples of the patient’s fibrous capsules above the cervical area of the Nobel Replace  dental implants revealed bacterial colonies a, Item 1The results of the tomographic studies are shown in To quantify the microinclusions contained in the sample, the obtained 3D image was processed, which included threshold filtering, binarization and labeling. The resulting projection of all the inclusions after this approach is shown in EqD), representing the diameters of a sphere of the same volume, were calculated according to the following equation:During the analysis, the following parameters were determined: spatial distribution, dimensions  and the average linear absorption coefficients  of the f−1 were detected (BN is the number of particles and V is the volume. For the volume of the studied sample (~3.3 × 1010 µm3) and the number of detected microparticles (~700), the concentration was ~4.6 × 107 µm−3.It should be noted that a large number of microinclusions with sizes from ~11 to 235 μm with linear absorption coefficients µ from ~0.22 to 0.6 mmdetected . Thus, tThe results of the study of the elemental composition inside the soft tissue biopsy specimens  by XRF are presented in 2, space group P42/mnm) and anatase . In the case of the Alpha-Bio implants, in addition to titanium dioxide and titanium nitride, aluminum oxides were present. The elemental composition of the nanoscale particles showed the presence of elements such as Fe, V, Ca, Na, Cl, S, Si and P. There was a correlation between the established composition of the metal particles and the composition declared by the manufacturers of these dental systems [In the earlier studies  of the s systems ,20. The In addition, it was previously discovered  that theIn the process of the clinical case studies in the present work, XMCT and XRF were used to identify the impregnated MSMP in the structure of the pathological areas of tissue . It was A comparison of the results of clinical studies of soft tissue biopsy specimens with analyses of the composition of the supernatant obtained from the surface of newly certified medical devices from the same manufacturer made it possible to assess the involvement of NSMP in the development of chronic inflammatory complications. Dental implants from another leading manufacturer were used for comparison and to obtain reliable statistical data.According to the chemical element distribution maps, the sample contained particles of Fe, Zn, Al, Zr, Si oxides and Ti. The particle sizes ranged from a few tens of nanometers to a few micrometers, and the shape was random. Elements such as P, Mg, S and K were distributed uniformly over the particle area shown in the STEM images. The Cu peaks for all spectra obtained by transmission electron microscopy appeared to be caused by the presence of the copper grid on which the particles under study were placed. Since the particles were on a carbon substrate, it was not possible to determine the carbon content of the particles.As in the previous case, Ti, Al, Fe and Si oxides up to several micrometers in size were revealed most often. There were also single particles of Ba, Cr, Zn, Mg, Cl and N, which were distributed uniformly over the image’s area.Frequency of occurrence: Nobel Replace, 6.4 kcps; Alpha-Bio, 6.0 kcps;NSMP size: Nobel Replace, 103.31 nm; Alpha-Bio, 187.75 nm;Polydispersity: Nobel Replace, 0.744%; Alpha-Bio, 0.480%.The parameters of NSMP in the supernatants of the Nobel Replace and Alpha-Bio systems, determined by DLS at a dilution ratio of 1.0, were as follows:The activation of THP-1 line cells under the influence of lipopolysaccharide (LPS) on the two dental implant systems was estimated according to the expression level of CD54 on the cells’ surface .The data presented in Stimulation of the cells simultaneously with LPS and human blood plasma also caused a significant increase in the expression of CD54 (p<0.001) d. The grThe data obtained after incubation of the cells with NSMP of Nobel Replace are shown in The results of estimating the cell viability of the THP-1 line under the influence of NSMP from the two dental implant systems in this study are shown in During the co-culture of the THP-1 cells with NSMP obtained from the surface of Alpha-Bio dental implants, a statistically significant decrease in cell viability against the background of exposure to high concentrations of the particles was observed, which did not depend on the presence of co-stimulants. The maximum contribution (90.02%) to the total dispersion was made by the particle concentration factor (Cell death processes at early stages (early apoptosis) were determined by both the NSMP concentration factor   was 47 years old. At the Department of Oral Surgery No. 2 of the Moscow State University of Medicine and Dentistry, classical two-stage dental implant surgery was performed using the Nobel Replace implant system for the patient S. After three months, the second surgical stage of dental implantation requiring the installation of gum shapers was performed. During this stage, fibrous capsules above the surface of the right dental implants in Projections 45, 46 and 47, as well as bone resorption in the cervical area of dental implants were revealed at a depth of 3 mm a. It shoHistological studies of the soft tissue samples (fibrous capsules) located above the cervical area of the dental implants were performed after the second surgical stage of dental implantation and biopsy sampling. The material was placed in a 10% solution of neutral formalin for 72 h, after which, the tissue samples were washed in running water for 2 h. After standard histological preparation, the tissue samples were embedded in paraffin , using histological pouring rings . Serial and semi-serial slices were made from the blocks on a Microm microtome (3–7 μm). The specimens were stained by Mallory technique  to reveal specific processes of connective tissue formation.X-ray absorption microtomography was used to identify external inclusions in the specimens under study, which were a part of the fibrous capsule adjacent to the cervical zone of the Nobel Replace dental implant system, and to determine their spatial distribution and size. The measurements were performed on a “TOMAS” X-ray microtomograph using an X-ray tube with a molybdenum anode  and a pyrolytic graphite monochromator single crystal (the size of the beam on the object was about 1 cm). The parameters of the experiments were as follows: source–sample distance, 1.2 m, sample–detector distance, 0.02 m. The probing conditions were an accelerating voltage of 40 kV and a current of 40 mA. The sample was rotated around a fixed vertical axis and 400 projections were measured with a step of 0.5 degrees and 4 s of exposure time per frame. A high-resolution X-ray detector, XIMEA-xiRay11 , with a 9 μm pixel size and a 36 × 24 mm field of view was used for the measurements. The reconstruction was performed by the algebraic method using ASTRA Toolbox software v. 2.1 .α1 line of molybdenum. The lower threshold of the measurements was limited by the parameters of the detector’s sensitive element of ~1 keV, and the energy resolution was ~150 eV. The parameters of the experiment were as follows: a source–sample distance of about 1 m and a sample–detector distance of about 0.02 m. The size of the probing beam on the sample was 1 × 3 mm (h × v). The probing conditions were an accelerating voltage of 40 kV and a current of 40 mA. The exposure time was 600 s.The elemental composition of the sample  was determined by X-ray fluorescent analysis on an X-ray microtomograph using an X-123SDD detector-spectrometer . The radiation source was an X-ray tube with a molybdenum anode, of which the radiation was monochromatized by a single reflection from a highly perfect symmetric silicon single crystal, Si(111). The radiation energy of 17.47 keV corresponded to the characteristic KThe surface composition of the dental implant was studied by transmission electron microscopy (TEM), scanning transmission electron microscopy (STEM) with z-contrast and energy-dispersive X-ray (EDX) analysis using a transmission electron microscope with field emission  at an accelerating voltage of 200 kV. The transmission electron microscope was equipped with a special system of detectors allowing us to obtain maps of the chemical elements’ distribution across a large area in a few minutes.For the TEM analysis, supernatant samples containing nanoscale oxide film elements obtained from the surface of the dental implants were prepared by the method described in the patent . Superna2 incubator. Nanoscale particles were obtained by the method described in the patent [To obtain supernatants containing NSMP used in the experimental part of the study, 40 units of the Nobel Replace and Alpha-Bio dental implant systems were incubated in double-distilled water for 5 days in a COe patent . After iThe method of dynamic light scattering (photon correlation or quasi-elastic light scattering) can be used to measure objects from 1 nm to 10 µm in size, which allowed us to detect the yield of NSMP and MSMP  from the objects of this study .To identify nanoscale particles from the surfaces of the two dental implant systems in the supernatants  and to dUsing the DLS method, three parameters were measured: the NSMPs’ diameter , the frequency of the NSMPs’ occurrence in the supernatants  and the index of heterogeneity of the NSMP’s distribution in the supernatants, known as NSMP polydispersity . The MS Excel software package (Microsoft Office 2016) was used to process the statistical data for the two systems, i.e., Nobel Replace and Alpha-Bio.2 atmosphere. Plastic vials with a volume of 50 mL  were used. For the experiments, 250 µL of the cell suspension (1 × 106 cells per mL) in RPMI-1640 culture medium was added to 96-well flat-bottom plates . Supernatants of the NSMP of the two dental implant systems at three different dilution ratios  were added to the wells to stimulate the cells. PBS was used as a negative control. In addition, supernatants containing NSMP were added to cells against the background of adding lipopolysaccharide and blood plasma from healthy donors separately and in combination. The incubation time in the presence of the stimulants was 24 h at 37 °C in a 5% CO2 atmosphere. After the incubation, the cells in each well were divided into two parts; the first part was used to estimate the viability and the second one was used to estimate the level of cell activation in the sample.The THP-1 suspension cell line (human monocytic leukemia cells) was chosen as the object of the present study. The THP-1 cells were cultured in RPMI-1640 medium  in the presence of 10% inactivated fetal calf serum , 50 µg/mL gentamicin  and 2 mM L-glutamine . Reseeding was performed every 2–3 days. The cells were incubated at 37 °C in a 5% COCell viability was assessed using the DNA-binding dyes YO-PRO-1 (iodide) and PI (Propidium Iodide Solution) . A speci5 cells/mL), obtaining a final concentration of 250 nM and 1 μg/mL, respectively. The staining was performed at room temperature for 5 min in a light-protected place.Cell staining was performed in 12 × 75 mm cytometric test tubes . For this purpose, solutions of YO-PRO-1  and PI  were added to 100 µL of the cell suspension . A two-component conjugate of mouse IgG1 immunoglobulin with FITC and phycoerythrin PE  was used as an isotypic control.Antibody staining was performed according to the manufacturer’s recommendations. The incubation time for the cells with the antibodies was 15 min at room temperature in a light-protected place. At the end of incubation, the samples were washed once with excess PBS at 330 g for 7 min, after which the supernatant was removed and the cell sediment was resuspended in PBS at pH 7.2–7.4, and a DAPI fluorescent dye solution  was added to the samples at a final concentration of 1 µg/mL to extract the live cell fraction.All samples were analyzed on a Navios flow cytofluorimeter  equipped with three diode lasers . To distinguish single cells from aggregates and subsequently discriminate the aggregates from the analysis, the following combinations of direct ) and lateral ) light scattering signals were used: the peak intensity compared with the integral signal’s intensity determined by FS or SS, and the flight time compared with the integral signal’s intensity determined by FS or SS. At least 30,000 single cells were analyzed in each sample. The results were analyzed using Kaluza software .When assessing the degree of viability based on YO-PRO1 and PI fluorescence, the entire cell pool was divided into three populations: live cells (YO-PRO1−/PI−), cells in the early stages of apoptosis (YO-PRO1+/PI−) and cells in the late stages of apoptosis/necrosis (YO-PRO1+/PI+). The number of cells in these populations was expressed as a percentage of the total number of cells. The gating tactics are shown in The average CD54-FITC fluorescence signal level  was analyzed to assess the degree of cell activation. The results are presented in units of fluorescence. The analysis was performed only for live cells (DAPI-), as described previously .To exclude the probability of aggregates of the studied nanoparticles entering the analysis zone, a calibration experiment was conducted in which nanoparticle solutions of different concentrations in the culture medium containing the studied substances were analyzed on a flow cytometer with similar settings to those used in the main experiment. It was found that the nanoparticles did not form aggregates that were registered by the device at the given settings and within the concentration limits used in the experiment.Statistical processing was performed by using the MS Excel software package  and GraphPad Prism 6.01 . The results are presented as the mean ± standard error of mean (mean ± SEM). Two-factor analysis of variance was used to compare quantitative values . Tukey’sThe results of a two-factor statistical analysis of the effects of NSMPs from the Nobel Replace and Alpha-Bio systems on activation, early and late apoptosis, and cell viability are presented in the The present clinical case and the results of a histological analysis of soft tissue biopsy specimens were the basis for multidisciplinary studies. It was shown that with the presence of a functional load in the process of dental implants’ osseointegration, the formation of microparticles in the compositions of fibrous capsules took place. X-ray and electron microscopy established that the composition of the detected nano- and microparticles corresponded to the composition of the dental implants. The presence of nanoparticles in the supernatants obtained from the surfaces of the dental implants of the two manufacturers’ systems was confirmed by DLS.As a result of the studies, the involvement of NSMP in both the physiological and pathophysiological processes of inflammation was confirmed. The presence of an autoimmune component in the pathogenesis of chronic immunopathological inflammation in tissues (mucositis and peri-implantitis) was experimentally proved.2 compound on human immune system cells in an experiment. Thus, a critical dose of nanoparticles leading to their coagulation to micron sizes under conditions of chronic inflammation was confirmed.By transferring the study to an in vitro model, it was possible to study the effect of nanoparticles of the “bioinert” TiOThis suggestion requires further multidisciplinary research in terms of improving preventive, diagnostic and therapeutic algorithms for the management of patients during implant treatment.


The cement industry is responsible for around 5% of global CO2 emissions. In this paper, the analysis of environmental and economic profits associated with the substitution of coal by two refuse-derived fuels (RDF) and sewage sludge (SS) in a cement kiln was presented. Differences in the fuel-related CO2 emissions were calculated for two-, three-, and four-component fuel blends based on the fuel consumption data, heating values, and the correspondent emission factors. The biogenic fraction content of 19% and 43% were measured in RDFs. The material balance of fuels with the assumed technological parameters of the cement clinker production installation (capacity of 6000 Mg per day and unit heat of 3.6 GJ) shows that the RDF heat substitution at the level of 90% allows for a saving of approximately 28.6 Mg per hour of coal, and to manage even approx. 40 Mg per hour of RDF. The increase in the share of SS in the total heat consumption to 6% contributed to reducing the actual emissions by 17 kg of CO2 per 1 Mg of clinker. Multilateral benefits due to the use of RDF in the cement plant were evident.The use of waste as an energy source in cement clinker production is a promising way to transition toward a circular economy and limit carbon dioxide (CO The cement industry is a model example of the transformation toward a circular economy . A circuThe assumptions of the idea of sustainable development and the efficient use of resources are implemented in many cement plants in Poland and around the world through the partial substitution of clinker in cement with raw materials of anthropogenic origin , humidity, and the content of non-flammable substances ,14. Rezambustion . Ash, a mbustion ,20. Thusmbustion . In cemembustion . High-cambustion , which imbustion . The calAccording to the specifications listed in the EN 15375:2011 standard , solid f2 emissions [2 emissions [The cement industry is now facing the pivotal and complex challenges of achieving the goals resulting from the EU Green Deal ,30 and tmissions . Currentmissions . From 20missions . Severalmissions ; in Allmmissions ; and in missions . In Polamissions ,36.2 emissions. Additionally, the substitution of coal with RDFs favors the development of economic activities related to collecting waste and processing it into alternative fuels. The decrease in emissivity results from the fact that alternative fuels have a lower carbon content than conventional fuels. Additionally, they contain a biogenic fraction for which a zero-emission factor is assumed. In Poland, alternative fuels may even contain over 30% of biomass. Den Boer and Jędrczak [w/w. The elemental analysis of the RDF samples from several municipal solid waste management plants [The strategy of increasing the share of heat from alternative fuels in the total heat consumption for cement clinker production will contribute to reducing the impact of cement plants on the environment and local communities by saving primary energy carriers, relieving local landfills and reducing the amount of landfilled waste, or reducing the COJędrczak  performeJędrczak  found tht plants  and a cet plants  showed tt plants ). Bielowt plants ,45 prese2 emissions and petroleum coke savings, when only 10–90% RDF was used as a supplementary fuel. Żygadło and Purgał [2 emissions from fuel combustion were presented mainly for two-component fuel blends , and the calculation was based on the default emission factors. The literature review revealed that the calculations of the CO2 emissions for multi-component fuel blends have not been published thus far. This paper was focused on addressing this knowledge gap. A case study was performed through the analysis of the benefits of two-, and also for three- and four-component fuel blends. Moreover, the calculation of CO2 emissions is based on the fuel analysis method, which involves determining the carbon content and calorific value of the fuel combusted. This method is more accurate and preferred for CO2 calculations over methods that rely on default emission factors. In the analysis, a variable share of heat flux from two refuse-derived fuels and sewage sludge was included. The amount of fuel being combusted was calculated based on the actual industrial values given by the Polish Cement Association, which collects data from all cement plants in Poland. It was assumed that RDFs of different contents of biogenic fraction were fed into the main burner and in the calciner, in this way, an additional value of this work is introduced. For the assumed technological parameters of the clinker burning installation, the optimal composition of the fuel blend was determined, which will allow for achieving the highest reduction in CO2 emissions. In addition, a cost analysis for each fuel configuration proposed was performed to estimate the savings from coal reduction in the fuel blend. The growing interest in the substitution of fossil fuel by waste fuels means that examining the prospects of CO2 in the greenhouse gas emissions and energy demand for different fuel configurations may be a valuable source of information for cement producers and a decision support in the CO2 emissions reduction policy.The assessment of the environmental and economic advantages in terms of the use of RDF and sewage sludge in cement plants was the objective of this paper. The benefits of a cement plant working on coal and partly replacing fossil fuels with an alternative fuel have been presented in many works ,46,47. T2 emissions from stationary combustion sources: (1) direct measurement of CO2 emissions through the use of a continuous emissions monitoring system and (2) the analysis of fuel input [2 calculations because emissions are directly related to the fuel’s carbon content.There are two main methods to estimate COel input . A case el input ,50. ThisIn the first step, the heat demand to produce the total mass of clinker was determined. According to the specific heat consumption and cement clinker production data published by the Polish Cement Association in 2021 , the tot2 emission factor was determined according to Equation (1):2 per terajoule (tCO2/TJ); 44/12 is a molar mass ratio of CO2 to C; CC is the carbon content, %; Q is the calorific value related to the unit mass, terajoule per Mg.Based on the characteristics of the fuel being consumed, the CO2 emissions were calculated according to Equation (2):2CO denotes the total CO2 emissions from the fuel combustion process, Mg CO2, and M is the fuel combusted mass converted into the energy content, TJ per hour. Calculations regarding the fuel-related emissions and savings were carried out in Excel software.Next, the fuel-related CO2 emissions is partially determined by the uncertainty of activity data  and the uncertainty of the emission factor from the error in determining the calorific value and carbon content of the fuel.The accuracy of calculating the fuel-related CO2 emissions calculation are illustrated in The detailed steps of the COIn the next stage, the economic benefits of replacing coal by alternative fuels were calculated. The mass saving of the coal and thermal deficit that must be supplemented by the RDF fuel combustion heat was estimated.A multi-case study was performed by the analysis of the effects obtained by the substitution of coal with two refuse-derived fuels (RDF 1 and RDF 2) and sewage sludge (SS) see . To calcThirty-six fuel blends with different fuel  ratios were analyzed to determine the environmental and economic benefits. The percentage of heat from each fuel in the main burner/calciner is presented in The quality parameters of all of the analyzed fuels are summarized in 2 emissions as the sum of unit emissions from the combustion of coal, RDF and sewage sludge, and reduced the CO2 emissions. Reduced emissions are the amount of emissions, the balance of which considers the net zero-emission of CO2 from the combustion of the biogenic fraction contained in RDF 1, RDF 2, and sewage sludge. The combustion of biomass is considered to be CO2 neutral because the emitted amount of the gas is fully offset by the absorption through plant photosynthesis [The emissions balance for each analyzed blend included determining the actual COynthesis . The res2 emissions by about 1.7%. Thus, with the 60% substitution of heat with RDF 1, the actual CO2 emissions were lower by about 10% compared to the emissions from fossil fuel combustion alone. Considering the 20% share of biogenic fraction  in the total heat.As can be seen in fraction  in RDF 12 emissions, despite its zero-emission factor and low carbon content of 27.78% (2 emissions reduction was achieved with the share of heat from sewage sludge at the level of 6% (No. 2b/6). The calculated value of the reduced fuel emissions was only 6% lower than the CO2 emissions from coal combustion alone. The low level of CO2 emissions reduction for the fuel structure presented in 2 reduction as with the RDF 1 substitution of coal in the amount of 40–90%  and feeding 40–60% of RDF 2 (Nos. 3a/4–3a/6) than by substituting RDF 1 with 1–6% of sewage sludge in the total heat (Nos. 3b/1–3b/6). From the results in 2 emissions dropped by 2%. Meanwhile, it was noted that an increase in the share of sewage sludge in the fuel blend by each 1% resulted in reducing the total CO2 emissions by less than 1%. When co-combusting coal with RDF 1 and RDF 2 in the amount of 60% and 30% of the total heat (No. 3a/3), respectively, a comparable value of the total reduced CO2 emissions was obtained as in the case of 85% of RDF 1 and 5% of sewage sludge in the total heat (No. 3b/5).In three-component systems, a greater decline in CO2 per 1 Mg of clinker, and with a 10% share of heat (No. 3a/1), this value was 320.41 kg CO2 per 1 Mg of clinker. Taking into account the 43% share of the biogenic fraction  as a result of the partial replacement of coal with fuels containing the biogenic fraction was calculated concerning the emissions level of 366.86 kg of CO2 per 1 Mg of clinker  was obtained for the fuel configuration (No. 4a/6)  at a total of 90% including a 30% share of heat from RDF 2 and 6% share of heat from sewage sludge  is comparable to the level of CO2 reduction achieved for configuration No. 4b/6 . The increase in the share of heat from RDF 1 heated up in the burner to over 80% (No. 2a/6 and No. 3b/6) resulted in the actual CO2 emissions reduction by 14–15% in comparison with the emissions from the combustion of coal alone in the clinker burning system  [2 emissions allowances, the financial profit obtained due to the 10% substitution of coal with RDF 1 with the share of the CO2 emissions from neutral biomass amounted to EUR 615 per 1 Mg of clinker. At a higher share of RDF 1 of 90% in the total heat consumption, the profit from the avoided emissions would amount to EUR 5534 per 1 Mg of clinker. The total financial gain for the six selected configurations . The thermal deficit caused by a 90% reduction in coal in the total heat was 821,250 MJ and should be supplemented with about 34.2 Mg per hour of RDF 1 with the calorific value of 24.05 MJ/kg  , the priions see  with theThe calculations were made based on the material balance presented in 2 reduction and the consumption of RDFs was about 40–50 Mg per hour for the fuel variants. The results in 2 emissions had the most significant impact on the final financial balance.The list presented in 2 emissions and the savings of more expensive coal.The performed calculations showed that the change in the energy carrier in the clinker burning system from fossil fuel  to waste derived fuel containing the biomass fraction is highly profitable for the cement industry. This will contribute to the reduction in fuel-related CO2 emissions per mass of cement clinker production varied significantly among the compositions of the different fuel mixtures. It was observed that the introduction of low calorific fuel to the calciner increased the reduction in CO2 emissions by an additional 3%.It was found that the CO2 emissions reduction (from 366.86 kg of CO2 per 1 Mg of clinker to 233–257 kg of CO2 per 1 Mg of clinker) and the reduction in the production cost were obtained by working on the four-component mixture by substitution of 90% coal with 54% of RDF 1, 30% RDF 2, and 6% sewage sludge.The highest CO2 emissions, to 6%, reduced the CO2 emissions. However, in relation to the total emissions balance, their share of 2–17 kg CO2 per 1 Mg of clinker was insignificant. Co-combustion of coal with 6% of sewage sludge and RDFs containing the biomass fraction burnt in the calciner and the main burner at the level of 30% and approximately 60% of the total heat, respectively, turned out to be the most beneficial from the point of view of climate protection. A comparable level of reduction was also obtained in the co-combustion of coal with RDFs alone, but with two times the higher share of RDFs containing biomass fractions at the level of 43%.The increase in the amount of heat from the sewage sludge, which was considered neutral in terms of CO2 emission fees, gate fees for cement plants, and the reduction in the consumption of more expensive conventional fuels.The economic balance showed that increasing the share of energy from waste in the fuel structure in the clinker firing system contributes to the reduction in production costs due to lower CO2 emissions from the co-firing of gaseous fuel, because a big potential for CO2 reduction also lies in replacing coal with natural gas.The environmental benefit of replacing fossil fuels with alternative fuels in the cement industry also means eliminating millions of Mg of waste that cannot be recycled from the environment while preserving the reserves of fossil fuels. The results of the study confirm that the substitution of coal with waste fuel in the cement industry is one of the directions of activities supporting the implementation of the goals of the European Green Deal and the idea of a circular economy. However, this work had some limitations that can be improved upon in the future. This calculation only describes the benefits for cement producers, which was obtained by using the two selected refuse-derived fuels and sewage sludge. As is known, the problem related to the use of alternative fuels derived from waste is its heterogeneity, and thus the variability in the emissions factor. In the future, it is also worth carrying out a comparative study of CO