The Clinical Impact of the Pulmonary Embolism Severity Index on the Length of Hospital Stay of Patients with Pulmonary Embolism: A Randomized Controlled Trial.

BACKGROUND: The Pulmonary Embolism Severity Index (PESI) is an extensively validated prognostic score, but impact analyses of the PESI on management strategies, outcomes and health care costs are lacking. Our aim was to assess whether the adoption of the PESI for patients admitted to an internal medicine ward has the potential to safely reduce the length of hospital stay (LOS). METHODS: We carried out a multicenter randomized controlled trial, enrolling consecutive adult outpatients diagnosed with acute PE and admitted to an internal medicine ward. Within 48 h after diagnosis, the treating physicians were randomized, for every patient, to calculate and report the PESI in the clinical record form on top of the standard of care (experimental arm) or to continue routine clinical practice (standard of care). The ClinicalTrials.gov identifier is NCT03002467. RESULTS: This study was prematurely stopped due to slow recruitment. A total of 118 patients were enrolled at six internal medicine units from 2016 to 2019. The treating physicians were randomized to the use of the PESI for 59 patients or to the standard of care for 59 patients. No difference in the median LOS was found between the experimental arm (8, IQR 6-12) and the standard-of-care arm (8, IQR 6-12) (p = 0.63). A pre-specified secondary analysis showed that the LOS was significantly shorter among the patients who were treated with DOACs (median of 8 days, IQR 5-11) compared to VKAs or heparin (median of 9 days, IQR 7-12) (p = 0.04). CONCLUSIONS: The formal calculation of the PESI in the patients already admitted to internal medicine units did not impact the length of hospital stay.

Positive nutrition: shifting the focus from nutrients to diet for a healthy lifestyle.

PURPOSE AND METHODS: This summary is based on a scientific symposium organized by the Mediterranean Diet Roundtable and the American Italian Food Coalition titled, 'Positive Nutrition: shifting focus from nutrients to diet for a healthy lifestyle.' It was held at the Embassy of Italy in Washington DC in September of 2022. The panel of experts discussed how science can inform policy, what insights may be gleaned from different countries' approaches to healthy eating and what principles of the Mediterranean diet will inform strategies for a healthy future. Recognizing that isolated actions have limited impact on the complex relationship between diet and obesity, the panel discussed the importance of a system approach. In particular, the panel emphasized that focusing on single ingredients, isolated food categories and narrow approaches to policy have had limited success across the globe. RESULTS AND CONCLUSION: The panel agreed that there is a need for change of perspective that embraces complexity and emphasizes more positive nutrition messaging and policies. LEVEL OF EVIDENCE: V, Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Current perspectives on global sugar consumption: definitions, recommendations, population intakes, challenges and future direction.

Currently, there is considerable emphasis on the relationship between dietary sugar consumption and various health outcomes, with some countries and regions implementing national sugar reduction campaigns. This has resulted in significant efforts to quantify dietary sugar intakes, to agree on terms to describe dietary sugars and to establish associated recommendations. However, this information is infrequently collated on a global basis and in a regularised manner. The present review provides context regarding sugar definitions and recommendations. It provides a global review of the available data regarding dietary sugar intake, considering forms such as total, free and added sugars. A comprehensive breakdown of intakes is provided by age group, country and sugar form. This analysis shows that free sugar intakes as a percentage of total energy (%E) are the highest for children and adolescents (12-14%E) and the lowest for older adults (8%E). This trend across lifecycle stages has also been observed for added sugars. The available data also suggest that, while some reductions in sugar intake are observed in a few individual studies, overall intakes of free/added sugars remain above recommendations. However, any wider conclusions are hampered by a lack of detailed high-quality data on sugar intake, especially in developing countries. Furthermore, there is a need for harmonisation of terms describing sugars (ideally driven by public health objectives) and for collaborative efforts to ensure that the most up-to-date food composition data are used to underpin recommendations and any estimates of intake or modelling scenarios.

Incidence Rates and Case-Fatality Rates of Cerebral Vein Thrombosis: A Population-Based Study.

Background and Purpose: Cerebral vein thrombosis (CVT) incidence is estimated to be >10 per 1 000 000 per year. Few population-based studies investigating case-fatality rates (CFRs) and pyogenic/nonpyogenic CVT incidence are available. We assessed trends in CVT incidence between 2002 and 2012, as well as adjusted in-hospital CFRs and incidence of hospital admissions for pyogenic/nonpyogenic CVT in a large Northwestern Italian epidemiological study. Methods: Primary and secondary discharge diagnoses of pyogenic/nonpyogenic CVT were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes 325, 671.5, and 437.6. Age, sex, vital status at discharge, length of hospital stay, and up to 5 secondary discharge diagnoses were collected. Concomitant presence of intracerebral hemorrhage (ICH) was registered, and comorbidities were assessed through the Charlson comorbidity index. Results: A total of 1718 patients were hospitalized for CVT (1147 females­66.8%; 810 pyogenic and 908 nonpyogenic CVT, 47.1% and 52.9%, respectively), with 134 patients (7.8%) experiencing a concomitant ICH. The overall incidence rate for CVT was 11.6 per 1 000 000 inhabitants with a sex-specific rate of 15.1 and 7.8 per 1 000 000 in females and males, respectively. CVT incidence significantly increased in women during time of observation (P=0.007), with the highest incidence being at 40 to 44 years (27.0 cases per 1 000 000). In-hospital CFR was 3%, with no difference between pyogenic/nonpyogenic CVT. Patients with concomitant ICH had a higher in-hospital CFR compared with patients without ICH (7.5% versus 2.7%; odds ratio, 2.96 [95% CI, 1.45­6.04]). In-hospital CFR progressively increased with increasing Charlson comorbidity index (P=0.003). Age (odds ratio, 1.03 [95% CI, 1.02­1.05]), Charlson comorbidity index ≥4 (odds ratio, 4.33 [95% CI, 1.29­14.52]), and ICH (odds ratio, 3.05 [95% CI, 1.40­6.62]) were independent predictors of in-hospital mortality. Conclusions: In a large epidemiological study, CVT incidence was found to be comparable to the one registered in population-based studies reported after the year 2000. CVT incidence increased among women over time. In-hospital CFR was low, but not negligible, in patients with concomitant ICH. Age, ICH, and a high number of comorbidities were independent predictors of in-hospital mortality. Pyogenic CVT was not a predictor of in-hospital CFR, although its high proportion was not confirmed by internal validation.

Definition of major bleeding: Prognostic classification.

BACKGROUND: In patients on anticoagulant treatment, the major bleeding (MB) definition released by the International Society of Thrombosis and Haemostasis (ISTH) is widely accepted. However, this definition identifies MBs with highly variable short-term risk of death. OBJECTIVES: The study aims were to derive and validate a classification of ISTH-defined MBs for the risk of short-term death. METHODS: Consecutive patients admitted for ISTH-defined MB occurring while on treatment with oral anticoagulants were included in the study and divided into a derivation and a validation cohort. Death within 30 days was the primary study outcome. RESULTS: Among 1077 patients with MB, 64/517 and 63/560 patients in the derivation and validation cohort died, respectively. In the derivation cohort, Glasgow coma scale (GCS) <14 and shock were predictors of death; critical site bleeding and hemoglobin decrease ≥2 g/dL, or transfusion ≥ 2 units were not. GCS <14 (hazard ratio [HR], 8.67; 95% confidence interval [CI], 3.93-19.13) was predictor of death in intracranial hemorrhage (ICH) and shock at admission (HR, 4.84; 95% CI, 2.01-11.70) and pericardial bleeding (HR, 11.37; 95% CI, 1.33-97.31) in non-ICH MBs. The predictive value of GCS <14 in ICH and shock and pericardial bleeding in non-ICH MBs was confirmed in the validation cohort. None of the patients with isolated ocular or articular bleeding died. A prognostic classification of ISTH-defined MBs for the risk of short-term death is proposed as "serious," "severe," and "life-threatening" (ICH with GCS <14 or non-ICH with shock) MBs. CONCLUSION: According to our study, ISTH-defined MBs can be stratified for the risk of death within 30 days.

Prevalence and risk factors for pulmonary embolism in patients with suspected acute exacerbation of COPD: a multi-center study.

INTRODUCTION: Pulmonary embolism (PE) prevalence in acute exacerbations of COPD is highly variable. METHODS: To investigate the prevalence and risk factors of PE in patients hospitalized in Departments of Internal Medicine because of AECOPD and suspected PE we conducted a retrospective multicenter study in patients with an AECOPD undergoing chest angio-computed tomography (angio-CT) because of clinical suspect of PE. RESULTS: 1043 patients (mean age 75.8 years ± 9.7 years, 34.5 % women) were included; 132 patients had PE (mean prevalence 12.66%, 95% confidence interval 10.73, 14.77%).) confirmed by angio-CT and 54 patients died during hospitalization (5.18 %). At multivariate analysis, age, female gender, clinical signs and symptoms suggestive of deep vein thrombosis, hypertension, PaCO2 ≤ 40 mmHg, and normal chest-x-ray were significantly associated with a higher PE prevalence. Prevalence of PE in patients with 0, 1, 2, 3 or ≥4 risk factors progressively increase from 1.76 to 30.43%. Mean length of hospitalization (LOH) (15.7 vs 14.2 days, p 0.07) and in-hospital mortality (6.1% vs 5.1%, P=0.62) were slightly but not significantly higher in in patients with PE (6.1% vs 5.1%, P=0.62). CONCLUSIONS: PE prevalence is not negligible in this setting. A number of risk factors may help clinicians in identification of patients at increased risk of PE.

Mortality in patients with intracerebral hemorrhage associated with antiplatelet agents, oral anticoagulants or no antithrombotic therapy.

The association between preceding treatment with antiplatelet agents (APs), vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) and mortality after intracerebral hemorrhage (ICH) remains unclear. The aim of this multicenter, prospective cohort study was to assess the risk for death after ICH in consecutive patients who were on treatment with APs, VKAs, DOACs, or no antithrombotic agent. The primary outcome was in-hospital death by day 30. ICH volume at admission and volume expansion were centrally assessed. Out of 598 study patients, in-hospital death occurred in 21% of patients who were on treatment with APs, 25% with VKAs, 30% with DOACs, and 13% with no antithrombotics. Crude death rate was higher in patients on antithrombotics as compared to patients receiving no antithrombotic agent. At multivariate analysis, age (HR 1.07; 95% CI 1.04-1.10), previous stroke (HR 1.83; 95% CI 1.14-2.93), GCS ≤8 at admission (HR 6.06; 95% CI 3.16-9.74) and GCS 9-12 (HR 3.38; 95% CI 1.81-6.33) were independent predictors of death. Treatment with APs (HR 1.29; 95% CI 0.61-2.76), VKAs (HR 1.42; 95% CI 0.70-2.88) or DOACs (HR 1.28; 95% CI 0.61-2.73) were not predictors of death in the overall study population, in non-trauma associated ICH as well as when GCS was not included in the model. ICH volume and volume expansion were independent predictors of death. In conclusion, preceding treatment with antithrombotic is associated with the severity of ICH. Age, previous stroke and clinical severity at presentation were independent predictors of in-hospital death in patients with ICH.

GutSelf: Interindividual Variability in the Processing of Dietary Compounds by the Human Gastrointestinal Tract.

Nutritional research is currently entering the field of personalized nutrition, to a large extent driven by major technological breakthroughs in analytical sciences and biocomputing. An efficient launching of the personalized approach depends on the ability of researchers to comprehensively monitor and characterize interindividual variability in the activity of the human gastrointestinal tract. This information is currently not available in such a form. This review therefore aims at identifying and discussing published data, providing evidence on interindividual variability in the processing of the major nutrients, i.e., protein, fat, carbohydrates, vitamins, and minerals, along the gastrointestinal tract, including oral processing, intestinal digestion, and absorption. Although interindividual variability is not a primary endpoint of most studies identified, a significant number of publications provides a wealth of information on this topic for each category of nutrients. This knowledge remains fragmented, however, and understanding the clinical relevance of most of the interindividual responses to food ingestion described in this review remains unclear. In that regard, this review has identified a gap and sets the base for future research addressing the issue of the interindividual variability in the response of the human organism to the ingestion of foods.

The complexity of patients hospitalized in Internal Medicine wards evaluated by FADOI-COMPLIMED score(s). A hypothetical approach.

OBJECTIVES: The aim of this study is to develop a new predictive model to measure complexity of patients in medical wards. SETTING: 29 Internal Medicine departments in Italy. MATERIALS AND METHODS: The study cohort was made of 541 consecutive patients hospitalized for any cause, aged more than 40 years and with at least two chronic diseases. First, we applied a hierarchical cluster analysis and the principal component analysis (PCA) to a panel of questionnaires [comorbidity (Charlson, CIRS), clinical stability (MEWS), social frailty (Flugelman), cognitive dysfunction (SPSMQ), depression (5-item GDS), functional dependence (ADL, IADL, Barthel), risk of sore threats (Exton-Smith scale), nutrition (MNA), pain (NRPS), adherence to therapy (Morisky scale)], in order to select domains informative for the definition of complexity. The following step was to create the score(s) needed to quantify it. RESULTS: Two main clusters were identified: the first includes 7 questionnaires whose common denominator is dependence and frailty, the second consists of 3 questionnaires representative of comorbidity. Globally, they account for about 70% of the total variance (55.2% and 13.8%, respectively). The first principal component was simplified in "Complimed Score 1" (CS1) as a recalibrated average between the Barthel Index and the Exton Smith score, whereas the second cluster was approximated to "Complimed Score 2" (CS2), by using the Charlson score only. CONCLUSIONS: Complexity is a two-dimensional clinical phenomenon. The FADOI-Complimed Score(s) is a new tool useful for the routine evaluation of complexity in medical patients, simple to use and taking around 10 minutes to complete.

Pulmonary embolism prognostic factors and length of hospital stay: A cohort study.

INTRODUCTION: Patients with pulmonary embolism (PE) are commonly admitted to hospital for their initial treatment. We aimed to assess the association of length of hospital stay with commonly available clinical variables and their combinations. METHODS: A retrospective multicenter cohort study was conducted on consecutive PE patients admitted to eight Italian centers. Logistic regression analysis was performed to evaluate the association between the length of hospital stay and the Pulmonary Embolism Severity Index (PESI) parameters, National Early Warning Score (NEWS) and other possible determinants. RESULTS: We enrolled 391 patients, with a median hospital stay of 10days (IQR 7-14). Among PESI parameters, only oxygen saturation <90% was significantly associated with length of hospital stay at univariable analysis (OR 1.99; 95% CI 1.3-3.2). At multivariable analysis, NEWS ≥5 was associated with prolonged hospitalization (OR 3.14; 95% CI 1.2-8.3). A difference of median hospital stay was found between simplified PESI high and low risk groups (10 and 9days, respectively, p=0.027). DISCUSSION: The median duration of hospital stay was generally long and not influenced by single parameters of PESI or common prognostic factors. The difference of one day between the low- and high-risk groups according to simplified PESI was not clinically significant.

Incidence rates and case fatality rates of portal vein thrombosis and Budd-Chiari Syndrome.

Little information is available on the incidence of splanchnic vein thrombosis and on mortality rates during the acute phase of the disease. We performed a large epidemiologic study on hospital admissions for portal vein thrombosis (PVT) and the Budd-Chiari syndrome (BCS) between 2002 and 2012 in Northwestern Italy. Primary and secondary discharge diagnoses of PVT and BCS were identified using the 9th edition International Classification of Diseases codes 453.0, 572.1 and 452. Hospitalisations for recurrent events were not included. Information was collected on age and gender, vital status at discharge, duration of hospitalisation, and up to five secondary discharge diagnoses. Comorbidity was evaluated using the Charlson comorbidity index (CCI). A total of 3535 patients with PVT and 287 with BCS were hospitalized. The overall gender-specific incidence rates for PVT were 3.78 per 100,000 inhabitants in males and 1.73 per 100,000 inhabitants in females; for BCS 2.0 and 2.2 per million inhabitants, respectively. In-hospital case fatality was 7.3 % in patients with PVT and 4.9 % in patients with BCS. Age, non-abdominal solid cancer, and CCI were independently associated with in-hospital mortality in both PVT and BCS after stepwise regression analysis, male gender and haematologic cancer were associated with mortality in BCS patients only. In this large study we confirmed the low incidence of BCS and we found an incidence of PVT higher than previously reported. This incidence was stable during the period of observation. In-hospital mortality is not negligible, in particular in PVT patients.

Dairy products and inflammation: A review of the clinical evidence.

Inflammation is a major biological process regulating the interaction between organisms and the environment, including the diet. Because of the increase in chronic inflammatory diseases, and in light of the immune-regulatory properties of breastfeeding, the ability of dairy products to modulate inflammatory processes in humans is an important but unresolved issue. Here, we report a systematic review of 52 clinical trials investigating inflammatory markers in relation to the consumption of dairy products. An inflammatory score (IS) was defined to quantitatively evaluate this interaction. The IS was significantly positive for the entire data set, indicating an anti-inflammatory activity in humans. When the subjects were stratified according to their health status, the IS was strongly indicative of an anti-inflammatory activity in subjects with metabolic disorders and of a pro-inflammatory activity in subjects allergic to bovine milk. Stratifying the data by product categories associated both low-fat and high-fat products, as well as fermented products, with an anti-inflammatory activity. Remarkably, the literature is characterized by a large gap in knowledge on bioavailability of bioactive nutrients. Future research should thus better combine food and nutritional sciences to adequately follow the fate of these nutrients along the gastrointestinal and metabolic axes.

Satiety Impact of Different Potato Products Compared to Pasta Control.

OBJECTIVE: A variety of potato dishes are regularly consumed worldwide, but the satiety value of these foods is not well established. The primary objective of this study was to compare the satiating effects of 4 equi-energy meals containing different potato preparations with an equi-energy pasta control meal. METHODS: This study used a randomized crossover design to assess the impact of 4 equi-energy potato-based meals (fried French fries, baked potato, mashed potato, or potato wedges) on subjective satiety sensations (visual analogue scale [VAS] ratings) and subsequent energy intake (ad libitum meal [kcal]), compared to a control pasta-based meal. Thirty-three healthy nonobese men and women participated in the study. RESULTS: VAS ratings indicated that the meal containing fried french fries was perceived to be substantially more satiating than the equi-energy pasta control meal, with all other potato-based meals not differing overall from control. All test meals had a comparable effect on energy intake at a later ad libitum meal. CONCLUSIONS: Consumers reported higher levels of satiety following a meal where the principal carbohydrate source was fried french fries, compared to when they had consumed an energy-matched meal containing carbohydrate in the form of pasta. All other potato preparations had similar effects on satiety as pasta. It is concluded that participants perceived a meal with fried french fries as providing greater satiety than a pasta control meal.

A mid-morning snack of almonds generates satiety and appropriate adjustment of subsequent food intake in healthy women.

PURPOSE: To assess the effect of consuming a mid-morning almond snack (28 and 42 g) tested against a negative control of no almonds on acute satiety responses. METHOD: On three test days, 32 healthy females consumed a standard breakfast followed by 0, 28 or 42 g of almonds as a mid-morning snack and then ad libitum meals at lunch and dinner. The effect of the almond snacks on satiety was assessed by measuring energy intake (kcal) at the two ad libitum meals and subjective appetite ratings (visual analogue scales) throughout the test days. RESULTS: Intake at lunch and dinner significantly decreased in a dose-dependent manner in response to the almond snacks. Overall, a similar amount of energy was consumed on all three test days indicating that participants compensated for the 173 and 259 kcals consumed as almonds on the 28 and 42 g test days, respectively. Subjective appetite ratings in the interval between the mid-morning snack and lunch were consistent with dose-dependent enhanced satiety following the almond snacks. However, in the interval between lunch and dinner, appetite ratings were not dependent on the mid-morning snack. CONCLUSION: Almonds might be a healthy snack option since their acute satiating effects are likely to result in no net increase in energy consumed over a day.

Validation of an iPad visual analogue rating system for assessing appetite and satiety.

The study aimed to validate appetite ratings made on a new electronic device, the Apple iPad Mini, against an existing but now obsolete electronic device (Hewlett Packard iPAQ). Healthy volunteers (9 men and 9 women) rated their appetite before and 0, 30, 60, 90 and 120 minutes after consuming both a low energy (LE: 77 kcal) and high energy (HE: 274 kcal) beverage at breakfast on 2 non-consecutive days in counter-balanced order. Rated hunger, desire to eat and how much participants could consume was significantly lower after HE than LE on both devices, although there was better overall differentiation between HE and LE for ratings on iPad. Rated satiation and fullness, and a composite measure combining all five ratings, was significantly higher after HE than LE on both devices. There was also evidence that differences between conditions were more significant when analysed at each time point than using an overall area under the curve (AUC) measure. Overall, these data confirm that appetite ratings made using iPad are at least as sensitive as those on iPAQ, and offer a new platform for researchers to collect appetite data.

Consuming polydextrose in a mid-morning snack increases acute satiety measurements and reduces subsequent energy intake at lunch in healthy human subjects.

Polydextrose (Litesse®, DuPont) is a polysaccharide that is partially fermented in the colon. Evidence suggests that polydextrose increases satiety when consumed over several weeks; however studies assessing its acute effects on satiety are lacking. This study therefore aimed to assess the impact of different doses of polydextrose on satiety and energy intake at subsequent meals during a test day. Three yogurt-based drinks containing different amounts of polydextrose (0, 6.25 and 12.5g) were tested using a randomised, single-blinded, placebo controlled, cross-over design. Thirty-four healthy male and female volunteers were provided with a standard breakfast, then consumed the test product mid-morning, 90min before an ad libitum lunch, which was followed by an ad libitum dinner. Visual analogue scales were used to measure subjective ratings of appetite, liking and discomfort. Consuming 6.25 and 12.5g polydextrose increased satiety and decreased appetite compared to control immediately after consumption. A reduction in energy intake (218.8kJ) at lunchtime was observed for 12.5g polydextrose. This reduction in energy intake was not compensated for at dinner. This study suggests that polydextrose may aid in increasing satiety feelings post consumption and also reduce energy intake as a result.

Effects of food processing on flavonoids and lycopene status in a Mediterranean tomato variety.

This research is focused on the antioxidant properties of dietary components, in particular phenolics and carotenoids and the assessment of the contribution of the combined antioxidants to the total antioxidant activity (TAA) of tomato fruit. The aim of this study was to analyse the effects of processing on the antioxidant properties of tomato. The effects of three different methods of processing fresh tomatoes into tomato sauce were investigated with respect to the antioxidant properties of the fruit. Identification and quantification of the main carotenoids and flavonoids present in tomatoes was achieved by HPLC analysis and the effect on the concentration and availability of these compounds was investigated at different stages of the processing. The processing affected mainly naringenin causing a reduction in the concentration. Conversely, levels of chlorogenic acid were increased suggesting an improvement in availability of this compound to extraction. The concentration of all-trans-lycopene was also increased following processing. Less than 10% isomerisation of all-trans-lycopene to the cis form was detected for all the methods analysed. The effects of processing on the overall antioxidant activity support the theory of a general improvement in availability of individual antioxidants. For both hydrophilic and lipophilic extracts TAA values were increased.