Assessing the Association between Biomarkers and COVID-19 Mortality Using the Joint Modelling Approach.

We evaluated the association between biomarkers and COVID-19 mortality. Baseline characteristics of 403 COVID-19 patients included sex and age; biomarkers, measured throughout the follow-up, included lymphocytes, neutrophils, ferritin, C-reactive protein, glucose, and LDH. Hazard ratios (HRs) and corresponding 95% credible intervals (CIs) were estimated through joint models (JMs) using a Bayesian approach. We fitted univariable (a single biomarker) and multivariable (all biomarkers) JMs. In univariable analyses, all biomarkers were significantly associated with COVID-19 mortality. In multivariable analysis, HRs were 1.78 (95% CI: 1.13-2.87) with a doubling of neutrophils levels, 1.49 (95% CI: 1.19-1.95) with a doubling of C-reactive protein levels, 2.66 (95% CI: 1.45-4.95) for an increase of 100 mg/dL of glucose, and 1.31 (95% CI: 1.12-1.55) for an increase of 100 U/L of LDH. No evidence of association was observed for lymphocytes and ferritin in multivariable analysis. Men had a higher COVID-19 mortality risk than women (HR = 1.75; 95% CI: 1.07-2.80) and age showed the strongest effect with a rapid increase from 60 years. These findings using JM confirm the usefulness of biomarkers in assessing COVID-19 severity and mortality. Monitoring trend patterns of such biomarkers can provide additional help in tailoring the appropriate care pathway.

A Plant-Based Cholesterol-Lowering Diet Score Correlates with Serum LDL-Cholesterol Levels.

BACKGROUND: A cholesterol-lowering diet score was previously developed for epidemiological studies; its association with serum lipid profile was not confirmed yet. METHODS: The score was developed as an adaptation of the dietary portfolio for cholesterol reduction, assigning one point for adherence to seven dietary indicators and ranging from 0 (null adherence) to 7 (highest adherence). The score was calculated for breast cancer patients enrolled in the DEDiCa study using a 7-day food record; serum lipid profile, including total and low-density lipoprotein cholesterol (LDL-C), was evaluated in serum at baseline. RESULTS: Patients with the highest adherence to the cholesterol-lowering diet (i.e., score ≥ 4) reported lower LDL-C level than women with score 0-1 (median: 107 mg/dL and 122 mg/dL, respectively; p < 0.01). The proportion of women with LDL-C above the recommended limit of 116 mg/dL was 60.0% with score 0-1 and 42.6% with score ≥4. Although the score directly correlates with consumption of foods from vegetal sources, it was mildly associated with the healthful plant-based diet index (r-Spearman = 0.51) and the Mediterranean Diet Adherence Screener (r-Spearman = 0.30) Conclusions: These results provide experimental evidence that the cholesterol-lowering diet score is capable of detecting a specific plant-based dietary pattern that affects circulating cholesterol levels.

A novel approach to assess diet diversity: a development of the Nutritional Functional Diversity indicator.

Background and aims: Diversity is a key element of diet quality. The Food Variety Score (FVS) is used to assess diversity, especially in low- and middle-income countries. It sums up the number of foods consumed ignoring their nutrient content. A more suitable index should combine the number of foods consumed and their nutritional composition. We adapted the Nutritional Functional Diversity indicator (NFD), proposed by ecologists, to measure diversity in the human diet. We compared NFD and FVS evaluating subjects' distributions across quartiles of the two diversity indices. To evaluate which one reflected a higher diet quality, we estimated associations between these two diversity indices and diet quality measures, i.e., the Mediterranean Diet Score (MDS) and the Healthy Eating Index-2015 (HEI-2015). Associations were expressed by odds ratios (OR) and corresponding 95% confidence intervals (CI). Materials and methods: We used the data of controls only derived from an integrated series of hospital-based case-control cancer studies conducted in different Italian areas. The NFD identifies groups of foods based on a set of nutrients according to a cluster analysis. Some steps are required: creating a food-nutrient matrix; clustering of the Euclidean food-food distance matrix to identify groups of foods with nutritional (dis)similarities; and calculating the NFD as the ratio between the sum of branch lengths of the dendrogram belonging to the number of foods consumed by individuals (i.e., subject-specific diversity) and the sum of all branch lengths of the dendrogram (i.e., maximal diversity). Results: More than one quarter of individuals (28.4%) were differently classified within quartiles of the two diversity indices. For both indices, increasing the diversity level increased the risk for adhering to MDS (OR for NFD = 11.26; 95% CI: 7.88-16.09, and OR for FVS = 6.80; 95% CI: 4.84-9.54) and to HEI-2015 (OR for NDF = 2.86; 95% CI: 2.39-3.42, and OR for FVS = 2.72; 95% CI: 2.27-3.26). Associations were stronger for NFD. Conclusion: Our findings showed a greater ability of NFD to assess diet quality quantifying the degree of diversity.

Cancers attributable to overweight and obesity in Italy.

BACKGROUND & AIMS: Overweight and obesity are associated with multiple cancers. We quantified the burden of cancer attributable to overweight and obesity in Italy. METHODS: We estimated sex- and cancer site-specific population attributable fractions (PAFs) combining relative risks (from recent meta-analyses) with national obesity prevalence data (from a large sample survey conducted in 2005, to account for a 15-year lag period). Using nationwide mortality statistics and cancer registries data, we estimated the number of cancer cases and deaths attributable to overweight and obesity in Italy in 2020, based on the counterfactual scenario of a body mass index < 25 kg/m2. RESULTS: 3.6% of cancers in men and 4.0% in women in Italy were attributable to overweight and obesity, corresponding, respectively, to over 6900 and 7200 diagnoses in 2020. Attributable deaths were over 3600 in men and 2700 in women. PAFs (attributable cases) of overweight and obesity in men and women were, respectively, 38.1% (215 cases) and 21.8% (49 cases) for esophageal adenocarcinoma, 19.1% (1715 cases) and 14.5% (585 cases) for liver, 18.7% (1692 cases) and 16.7% (747 cases) for kidney, 13.7% (938 cases) and 10.1% (749 cases) for pancreatic, and 10.2% (2389 cases) and 3.4% (690 cases) for colorectal cancers. In women, PAFs were 22.3% (1859 cases) for endometrial and 5.7% (2556 cases) for post-menopausal breast cancer. CONCLUSIONS: The cancer burden associated with overweight and obesity in Italy is considerable, but smaller compared to other high income countries, likely because of the lower prevalence of overweight and obesity in the Italian population.

Cancer mortality associated with low education in Italy.

BACKGROUND: This study provides a nationwide representative quantification of the impact of educational inequalities on cancer mortality in Italy. METHODS: The study is based on prevalence data and mortality rate ratios according to levels of education obtained from the Italian 2011 census cohort, including >35 million individuals aged 30-74. We estimated the population attributable fraction (PAF) and the number of cancer deaths associated with low education (below university degree) in Italy by sex. RESULTS: PAFs for low levels of education were 29.1% among men and 13.3% among women, corresponding to 22,271 cancer deaths associated with low education in men and 7456 in women in 2019. PAFs by cancer site in men were: 53.0% for upper aerodigestive tract (UADT), 44.6% for liver, 41.3% for stomach, 41.3% for lung, 37.0% for bladder, 18.5% for colorectal, 9.8% for prostate and 9.1% for pancreatic cancers. PAFs in women were: 44.5% for cervical, 36.1% for UADT, 34.9% for stomach and 13.9% for colorectal cancers. The cancer sites with the highest number of deaths associated with low education were lung among men (7902/22,271, 35.5%) and colorectum among women (780/7456, 10.5%). CONCLUSIONS: About a quarter of cancer deaths in 2019 in Italy may be prevented by reducing the socioeconomic determinants that contribute to educational disparities in cancer mortality.

Cancers attributable to infectious agents in Italy.

OBJECTIVES: To provide an evidence-based, comprehensive assessment of the current burden of infection-related cancers in Italy. METHODS: We calculated the proportion of cancers attributable to infectious agents (Helicobacter pylori [Hp]; hepatitis B virus [HBV] and hepatitis C virus [HCV]; human papillomavirus [HPV]; human herpesvirus-8 [HHV8]; Epstein-Barr virus [EBV]; and human immunodeficiency virus [HIV]) to estimate the burden of infection-related cancer incidence (2020) and mortality (2017). Data on the prevalence of infections were derived from cross-sectional surveys of the Italian population, and relative risks from meta-analyses and large-scale studies. Attributable fractions were calculated based on the counterfactual scenario of a lack of infection. RESULTS: We estimated that 7.6% of total cancer deaths in 2017 were attributable to infections, with a higher proportion in men (8.1%) than in women (6.9%). The corresponding figures for incident cases were 6.5%, 6.9% and 6.1%. Hp was the first cause of infection-related cancer deaths (3.3% of the total), followed by HCV (1.8%), HIV (1.1%), HBV (0.9%), HPV, EBV and HHV8 (each ≤0.7%). Regarding incidence, 2.4% of the new cancer cases were due to Hp, 1.3% due to HCV, 1.2% due to HIV, 1.0% due to HPV, 0.6% due to HBV and <0.5% due to EBV and HHV8. CONCLUSIONS: Our estimate of 7.6% of cancer deaths and 6.9% of incident cases that were attributable to infections in Italy is higher than those estimated in other developed countries. Hp is the major cause of infection-related cancer in Italy. Prevention, screening and treatment policies are needed to control these cancers, which are largely avoidable.

Risk of stillbirth in singleton fetuses with advancing gestational age at term: A 10-year experience of late third trimester prenatal screenings of 50,000 deliveries in a referral center in northern Italy.

BACKGROUND: The risk of intrauterine death (IUD) at term varies from less than one to up to three cases per 1,000 ongoing pregnancies. The cause of death is often largely undefined. Protocols and criteria to prevent and define the rates and causes of stillbirth are the subjects of important scientific and clinical debates. We examined the gestational age and rate of stillbirth at term in a 10-year period at our maternity hub to evaluate the possible favorable impact of a surveillance protocol on maternal and fetal well-being and growth. METHODS AND FINDINGS: Our cohort included all women with singleton pregnancies resulting in early term to late term birth at our maternity hub between 2010 and 2020, with the exclusion of fetal anomalies. As per our protocol for monitoring term pregnancies, all women underwent near term to early term maternal and fetal well-being and growth surveillance. If risk factors were identified, outpatient monitoring was initiated and early- or full-term induction was indicated. Labor was induced at late term (41+0-41+4 weeks of gestation), if it did not occur spontaneously. We retrospectively collected, verified, and analyzed all cases of stillbirth at term. The incidence of stillbirth at each week of gestation, was calculated by dividing the number of stillbirths observed that week by the number of women with ongoing pregnancies in that same week. The overall rate of stillbirth per 1000 was also calculated for the entire cohort. Fetal and maternal variables were analyzed to assess the possible causes of death. RESULTS: A total of 57,561 women were included in our study, of which 28 cases of stillbirth (overall rate, 0.48 per 1000 ongoing pregnancies; 95% CI: 0.30-0.70) were identified. The incidence of stillbirth in the ongoing pregnancies measured at 37, 38, 39, 40, and 41 weeks of gestation was 0.16, 0.30, 0.11, 0.29, and 0.0 per 1000, respectively. Only three cases occurred after 40+0 weeks of gestation. Six patients had an undetected small for gestational age fetus. The identified causes included placental conditions (n = 8), umbilical cord conditions (n = 7), and chorioamnionitis (n = 4). Furthermore, the cases of stillbirth included one undetected fetal abnormality (n = 1). The cause of fetal death remained unknown in eight cases. CONCLUSIONS: In a referral center with an active universal screening protocol for maternal and fetal prenatal surveillance at near and early term, the rate of stillbirth was 0.48 per 1000 in singleton pregnancies at term in a large, unselected population. The highest incidence of stillbirth was observed at 38 weeks of gestation. The vast majority of stillbirth cases occurred before 39 weeks of gestation and 6 of 28 cases were SGA, and the median percentile of the remaining case was the 35th.

Sexual Dimorphism of Cranial Morphological Traits in an Italian Sample: A Population-Specific Logistic Regression Model for Predicting Sex.

Although not without subjectivity, the cranial trait scoring method is an easy visual method routinely used by forensic anthropologists in sex estimation. The revision presented by Walker in 2008 has introduced predictive models with good accuracies in the original populations. However, such models may lead to unsatisfactory performances when applied to populations that are different from the original. Therefore, this study aimed to test the sex predictive equations reported by Walker on a contemporary Italian population (177 individuals) in order to evaluate the reliability of the method and to identify potential sexual dimorphic differences between American and Italian individuals. In order to provide new reference data to be used by forensic experts dealing with human remains of modern/contemporary individuals from this geographical area, we designed logistic regression models specific to our population, whose accuracy was evaluated on a validation sample from the same population. In particular, we fitted logistic regression models for all possible combinations of the five cranial morphological traits (i.e., nuchal crest, mastoid process, orbital margin, glabella, and mental eminence). This approach provided a comprehensive set of population-specific equations that can be used in forensic contexts where crania might be retrieved with severe taphonomic damages, thus limiting the application of the method only to a few morphological features. The results proved once again that the effects of secular changes and biogeographic ancestry on sexual dimorphism of cranial morphological traits are remarkable, as highlighted by the low accuracy (from 56% to 78%) of the six Walker's equations when applied to our female sample. Among our fitted models, the one including the glabella and mastoid process was the most accurate since these features are more sexually dimorphic in our population. Finally, our models proved to have high predictive performances in both training and validation samples, with accuracy percentages up to 91.7% for Italian females, which represents a significant success in minimizing the potential misclassifications in real forensic scenarios.

Hypertensive Disorders of Pregnancy and Fetal Growth Restriction: Clinical Characteristics and Placental Lesions and Possible Preventive Nutritional Targets.

BACKGROUND: The purpose of this study was to describe the placental lesions in pregnancies complicated by hypertensive disorders (HDP) and/or fetal growth restriction (FGR) and in uneventful control pregnancies. METHODS: This is a case control study that included singleton pregnancies with HDP and normally grown fetus (HDP-AGA fetus), with HDP and FGR, early FGR, late FGR, and uneventful pregnancies. Feto-placental Doppler velocimetry and sFlt-1/PlGF ratio were performed. Placental histology was evaluated blinded according to the Amsterdam Consensus criteria. RESULTS: Placental lesions with maternal vascular malperfusion (MVM) were significantly more frequent in HDP-FGR and early FGR (92% and 83%). MVM were significantly associated with abnormal feto-placental Doppler parameters, especially in early FGR. Delayed villous maturation (DVM) was associated with late FGR (83%). HDP-AGA fetus cases presented a heterogeneous pattern of placental lesions, including 60% of cases with MVM, but were not associated with abnormal Doppler feto-placental velocimetry. CONCLUSIONS: We found a prevalence of placental maternal vascular malperfusion in HDP-FGR and early FGR groups. These lesions were also associated with abnormal, anti-, and angiogenic markers. Conversely HDP-AGA fetus and late FGR presented more heterogeneous placental lesions not severe enough to cause feto-placental Doppler anomalies. These conditions are likely associated with different etiologies, such as maternal pre-pregnancy risk factors for metabolic syndrome. These findings suggest a possible preventive nutritional approach in addition to low-dose aspirin in pregnant women with predisposing factors for HDP-AGA fetuses and late FGR.

Serum hepatic biomarkers in women with obstetric cholestasis and a concurrent SARS-CoV-2 infection.

AIM: The aim of the study was to evaluate the association between SARS-CoV-2 infection and serum hepatic biomarker levels among women with obstetric cholestasis. METHODS: In this prospective study, we recruited all pregnant women admitted in our hospital with obstetric cholestasis. Among those with a concurrent SARS-CoV-2 infection, we evaluated the following serum hepatic biomarkers: aspartate aminotransferase (AST), alanine aminotransferase (ALT), and biliar acids (BA). RESULTS: Among the 88 women enrolled in the study, 20 presented with a SARS-CoV-2 infection while 68 were negative. SARS-CoV-2 infected women were younger (mean age 30.5 ± 5.7 vs. 34.3 ± 5.4; p < 0.01) and in a greater percentage of non-Caucasian ethnicity when compared to noninfected women (60.0% vs. 17.6%; p < 0.01). Regarding levels of hepatic biomarkers, they showed higher levels of AST (111.5 ± 134.1 vs. 37.3 ± 43.4 UI/L; p = 0.02), ALT (132.2 ± 115.7 vs. 50.5 ± 73.173.1 UI/L; p < 0.01), and BA (41.4 ± 46.8 vs. 18.4 ± 13.4 µmol/L; p = 0.04) compared to noninfected patients. No significant differences in maternal or fetal outcomes were found between infected and noninfected women. CONCLUSION: SARS-CoV-2 infection was associated with higher levels of liver enzymes in patients with obstetric cholestasis. This could be the result of a possible hepatic involvement in patients with SARS-CoV-2 infection.

Adherence to Mediterranean Diet of Breastfeeding Mothers and Fatty Acids Composition of Their Human Milk: Results From the Italian MEDIDIET Study.

Background and Aims: The content of fatty acids (FA) in human milk may be influenced by maternal nutrition. We evaluated the role of a Mediterranean diet in influencing the content of FA in human milk among 282 breastfeeding mothers participating in the MEDIDIET study. Materials and Methods: Mediterranean Diet Score (MDS), a composite index, was used to evaluate adherence to the Mediterranean diet. It includes 9 components (i.e., vegetables, fruit, cereals, legumes, monounsaturated to saturated FA ratio - MUFA/SFA, fish, dairy products, meat, and alcohol) and therefore potentially ranges from 0 (no adherence) to 9 (complete adherence) points. None of the mothers obtained the highest score due to the low alcohol consumption in the study population. Mothers were categorized in approximate tertiles of adherence: 0-3 (34.4%), 4 (26.2%), and 5-8 points (39.4%). The mean content of FA across categories of MDS was compared using ANOVA and test for trend. Results: A high adherence of breastfeeding mothers to the Mediterranean diet was associated with lower content of SFA in human milk (42.58 ± 4.36 for MDS = 0-3, 42.58 ± 4.89 for MDS = 4, and 40.92 ± 5.22% of fats for MDS = 5-8 points; p ANOVA and p for trend = 0.02). Conversely, a high adherence was associated with higher content of MUFA in human milk (43.27 ± 4.27 for MDS = 0-3, 43.27 ± 4.47 for MDS = 4, and 45.24 ± 5.22% of fats for MDS = 5-8 points; p ANOVA and p for trend < 0.01), ω-3 FA (1.07 ± 0.25 for MDS = 0-3, 1.22 ± 0.49 for MDS = 4, and 1.31 ± 0.51% of fats for MDS = 5-8 points; p ANOVA and p for trend < 0.01), and the major types of ω-3 FA (i.e., α-linolenic acid - ALA, eicosapentaenoic acid - EPA, docosahexaenoic acid - DHA, docosapentaenoic acid - DPA). These associations were mainly driven by the adherence to the vegetables, MUFA/SFA, fish, and dairy products components of the Mediterranean diet. Conclusion: A high adherence to the Mediterranean diet was associated with human milk showing a lower content of SFA and higher content of MUFA and ω-3 FA, including DHA. The Mediterranean diet may contribute in human milk production with higher content of specific FA which is directly involved in infant's neural and visual development, as reported by previous studies.

Adherence to a cholesterol-lowering diet and the risk of prostate cancer.

Evidence suggests a role of serum cholesterol in prostate cancer (PCa) development and of lipid lowering medications in PCa risk reduction. We developed a score for adherence to an established cholesterol-lowering diet and evaluated its association with PCa risk in a multicentric hospital-based case-control study (1294 cases; 1451 matched controls) in Italy (1992-2001). The score was derived from seven dietary indicators which have been reported to lower cholesterol levels: high intake of non-cellulosic polysaccharides (viscous fibres), monounsaturated fatty acids, legumes, seeds/corn oil; low intake of saturated fatty acids, dietary cholesterol, and glycaemic index. Odds ratios (ORs) and corresponding confidence intervals (CIs) were calculated through the unconditional logistic regression model. Although most of the dietary indicators alone were not significantly associated with reduced PCa risk, men who fulfilled 5 to 7 dietary indicators (187 cases and 281 controls) showed a 43% reduction in PCa risk compared to those with 0 to 2 indicators (OR: 0.57; 95% CI: 0.43-0.77). This association was not modified by socio-demographic characteristics or lifestyle factors. In conclusion, adherence to a cholesterol-lowering diet is a favourable factor against the risk of PCa, providing support to dietary guidelines that promote cholesterol reduction through plant-based diets.

Altered Doppler Velocimetry of Fetal Middle Cerebral Artery in Singleton Pregnancies Complicated by Mild Well-Controlled Gestational Diabetes.

INTRODUCTION: The aim of the present study was to evaluate fetal umbilical artery (UA) and middle cerebral artery (MCA) blood flow in patients with gestational diabetes (GD), in order to determine whether minimal anomalies of glucose metabolism may influence fetal placental function. METHODS: UA and MCA flows were prospectively measured by transabdominal ultrasound in singleton pregnancies between 34 and 37 weeks of gestation. RESULTS: The study included 35 women with GD and 217 nondiabetic patients. Middle cerebral pulsatility index (PI) was significantly higher in the GD group (mean MCA-PI = 1.82 ± 0.27 vs. 1.71 ± 0.26; p < 0.02). Likewise, MCA peak systolic velocity (MCA-PSV) was higher in the GD group compared to the non-GD group, though the difference was not significant (mean of MCA-PSV = 47.14 ± 8.45 vs. 47.09 ± 11.21; p = 0.98). UA-PI resulted higher in the non-GD group without significant differences (mean of UA-PI = 0.88 ± 0.14 vs. 0.86 ± 0.15; p = 0.32). CONCLUSIONS: Our study shows that even in cases of minimal metabolic derangements, GD is characterized by a significant variation in fetal Doppler velocimetry, particularly in the brain.

Prelabor rupture of membranes at term: A possible hematological triage in addition to vagino-rectal beta-hemolytic streptococcus screening for early labor induction.

INTRODUCTION: A potential complication of term prelabor rupture of membranes (term PROM) is chorioamnionitis with an increased burden on neonatal outcomes of chronic lung disease and cerebral palsy. The purpose of the study was to analyze the efficacy of a standing clinical protocol designed to identify women with term PROM at low risk for chorioamnionitis, who may benefit from expectant management, and those at a higher risk for chorioamnionitis, who may benefit from early induction. MATERIAL AND METHODS: This retrospective study enrolled all consecutive singleton pregnant women with term PROM. Subjects included women with at least one of the following factors: white blood cell count ≥ 15×100/µL, C-reactive protein ≥ 1.5 mg/dL, or positive vaginal swab for beta-hemolytic streptococcus. These women comprised the high risk (HR) group and underwent immediate induction of labor by the administration of intravaginal dinoprostone. Women with none of the above factors and those with a low risk for chorioamnionitis waited for up to 24 hours for spontaneous onset of labor and comprised the low-risk (LR) group. RESULTS: Of the 884 consecutive patients recruited, 65 fulfilled the criteria for HR chorioamnionitis and underwent immediate induction, while 819 were admitted for expectant management. Chorioamnionitis and Cesarean section rates were not significantly different between the HR and LR groups. However, the prevalence of maternal fever (7.7% vs. 2.9%; p = 0.04) and meconium-stained amniotic fluid was significantly higher in the HR group than in LR group (6.1% vs. 2.2%; p = 0.04). This study found an overall incidence of 4.2% for chorioamnionitis, 10.9% for Cesarean section, 0.5% for umbilical artery blood pH < 7.10, and 1.9% for admission to the neonatal intensive care unit. Furthermore, no confirmed cases of neonatal sepsis were encountered. CONCLUSIONS: A clinical protocol designed to manage, by immediate induction, only those women with term PROM who presented with High Risk factors for infection/inflammation achieved similar maternal and perinatal outcomes between such women and women without any risks who received expectant management. This reduced the need for universal induction of term PROM patients, thereby reducing the incidence of maternal and fetal complications without increasing the rate of Cesarean sections.

Diet Quality as Measured by the Healthy Eating Index 2015 and Oral and Pharyngeal Cancer Risk.

BACKGROUND: Alcohol and tobacco are the major risk factors for oral and pharyngeal cancer, but diet is likely to have a role, too. OBJECTIVE: The objective was to analyze the relationship between adherence to the 2015-2020 Dietary Guidelines for Americans (DGA), as measured by the Healthy Eating Index 2015 (HEI-2015), and oral and pharyngeal cancer risk. Moreover, this work aimed to quantify the number of avoidable cases under different scenarios of increased adherence to the DGA, with the use of the potential impact fraction. This estimates the proportion of cases that would occur if the distribution of the risk factor in the population followed an alternative distribution. DESIGN: A multicenter, case-control study was conducted in Italy between 1991 and 2009. Participants' usual diet for the 2 years preceding study enrolment was assessed using a food frequency questionnaire. PARTICIPANTS AND SETTING: Cases were 946 patients admitted to major hospitals with incident, histologically confirmed oral and pharyngeal cancer. Controls were 2,492 patients admitted to the same hospitals for acute non neoplastic conditions. MAIN OUTCOME MEASURES: The adherence to the DGA was assessed using the HEI-2015 score (range = 0 to 100), based on 13 components. The outcome was oral and pharyngeal cancer. STATISTICAL ANALYSES PERFORMED: Odds ratios and the corresponding 95% CIs were estimated using multiple logistic regression models adjusted for tobacco, alcohol, and other relevant covariates. The potential impact fraction was estimated under different scenarios of adherence to the DGA. RESULTS: In this Italian population the HEI-2015 score ranged from 33.4 to 97.5. A higher HEI-2015 score was associated with a lower risk of oral and pharyngeal cancer, with an odds ratio of 0.70 (95% CI 0.62 to 0.79) for a 10-point increment of the score. The estimated potential impact fraction was 64.8% under the maximum achievable reduction scenario, and it ranged from 9% to 27% following other more feasible scenarios. CONCLUSIONS: The HEI-2015 score was inversely related to oral and pharyngeal cancer risk in this Italian population. This analysis allowed for the estimation of the fraction of preventable cases, under different feasible scenarios. A share of 9% to 27% of avoidable cases of oral and pharyngeal cancer might be obtained across real-world scenarios of adherence to the DGA as measured by the HEI-2015 score.

Dietary Intake of Breastfeeding Mothers in Developed Countries: A Systematic Review and Results of the MEDIDIET Study.

BACKGROUND: Lactation is a demanding period for women, and a good nutrition is crucial for optimal health of mothers and infants. OBJECTIVES: To provide new data and summarize the overall evidence on maternal nutrient intakes during lactation in developed countries, we present a systematic review (SR) of the literature and concurrently original results of the Italian MEDIDIET study. We compared nutrient intakes with dietary reference values (DRVs) proposed by the European Food Safety Authority. METHODS: Studies were identified searching PubMed/Embase databases up to February 2020. Observational studies reporting at least energy and macronutrient intakes of healthy breastfeeding mothers who followed non-restricted and non-specific diets were included. Studies on populations with severe nutritional deficiencies were excluded. The MEDIDIET study enrolled 300 healthy breastfeeding mothers at 6 ± 1 wk postpartum. Usual diet was concomitantly evaluated through a validated and reproducible FFQ. Nutrient intakes were estimated using a food composition database. RESULTS: Twenty-eight articles regarding 32 distinct study populations were included. Maternal nutrient intakes were generally in agreement across studies included in the SR and conforming to DRVs. Within micronutrients, vitamin D intake was below the recommendation. In the MEDIDIET study, mean intakes of energy (1950 ± 445 kcal/d), carbohydrates (270 ± 20.1 g/d), proteins (87.8 ± 20.1 g/d), and fats (65.6 ± 18.9 g/d) were similar to those observed in the SR. Moreover, observed intakes seemed to reflect the typical Mediterranean diet, with low intakes of carbohydrates, SFAs, and PUFAs and high intakes of MUFAs and vitamins. Conversely, protein intake was mainly derived from animal sources. CONCLUSIONS: This SR showed that nutrient intakes of breastfeeding mothers in developed countries are generally in line with DRVs despite different dietary patterns worldwide. Some nutritional deficiencies emerged, highlighting the need for additional nutritional advice. Mothers participating in the MEDIDIET study showed a nutritional profile in agreement with the Mediterranean diet.

Maternity ward management and COVID-19 pandemic: Experience of a single center in Northern Italy during lockdown.

INTRODUCTION: The aim of our study is to describe the management of a maternity ward in a referral center during the COVID-19 pandemic and 2020 lockdown. METHODS: This is a retrospective single-center study. We analyzed the records of all women consecutively admitted to our delivery ward during lockdown and compared them with those of women admitted in the same period in 2019. RESULTS: The number of patients (1260) admitted to our department in 2020 was similar (1215) to that in 2019. Among patients admitted during lockdown, 50 presented with a Sars-CoV-2 infection (3.9%). In 2020, the number of antenatal check-ups was lower than in 2019 [7.9 (1.5) vs 8.2 (1.3), p<0.001] and the rate of labor inductions was higher [436 (34.6) vs 378 (31.1), p=0.008] although no difference in delivery mode was found. Moreover, women admitted during lockdown were more likely to give birth alone [140 (11.1) vs 50 (4.1), p<0.001]. However, during 2020, the rate of mother and newborn skinto-skin contact [1036 (82.2) vs 897 (73.8), p<0.001] and that of breastfeeding within 2 hours from birth [1003 (79.6) vs 830 (68.3), p<0.001] was higher. We found no significant differences in maternal or neonatal outcomes. CONCLUSIONS: Despite the COVID-19 pandemic, we were able to guarantee a safe birth assistance to all pregnant women, both for those infected and those not infected by Sars-CoV-2.

Dietary Patterns of Breastfeeding Mothers and Human Milk Composition: Data from the Italian MEDIDIET Study.

(1) Background: Several studies have reported associations between maternal diet in terms of single foods or nutrients and human milk compounds, while the overall role of maternal diet and related dietary patterns has rarely been investigated. (2) Methods: Between 2012 and 2014, we enrolled 300 healthy Italian mothers, who exclusively breastfed their infant. During a hospital visit at 6 weeks postpartum, a sample of freshly expressed foremilk was collected and information on maternal dietary habits in the postpartum period was obtained through an interviewer-administered food frequency questionnaire. We applied principal component factor analysis to selected nutrients in order to identify maternal dietary patterns, and assessed correlations in human milk macronutrients and fatty acids across levels of dietary patterns. (3) Results: Five dietary patterns were identified, named "Vitamins, minerals and fibre", "Proteins and fatty acids with legs", "Fatty acids with fins", "Fatty acids with leaves", "Starch and vegetable proteins". These dietary patterns were correlated with some milk components, namely fatty acids, and in particular ω-3 and its subcomponents. (4) Conclusions: This study showed that overall maternal dietary habits during breastfeeding may influence human milk composition, suggesting the importance of adequate maternal nutrition during lactation not only for the mother herself but also to provide the infant with milk containing adequate amount and quality of nutrients for a balanced nutrition.

Sociodemographic characteristics of pregnant women tested positive for COVID-19 admitted to a referral center in Northern Italy during lockdown period.

INTRODUCTION: We investigated association between sociodemographic characteristics and COVID-19 disease among pregnant women admitted to our unit, the largest high-risk maternity unit in the Milan metropolitan area. METHODS: Between March 1, 2020 and April 30, 2020, 896 pregnant women were admitted to our Institution and tested for COVID-19. We collected information regarding their sociodemographic characteristics. Additional information on geographical area of residence, number of family members, number of family members tested positive for COVID-19, and clinical data was collected for women tested positive for COVID-19. Odds ratios (ORs) and 95% confidence intervals (CIs) for the risk of developing COVID-19 according to sociodemographic characteristics were estimated by unconditional logistic regression models. RESULTS: Among the 896 women enrolled, 50 resulted positive for COVID-19. Pregnant women aged ≥35 years had a significantly lower risk of developing the infection (crude OR = 0.29; 95% CI:0.16-0.55). Conversely, foreign women (crude OR = 3.32; 95% CI:1.89-5.81), unemployed women (crude OR = 3.09; 95% CI: 1.77-5.40), and women with an unemployed partner (crude OR = 3.16; 95% CI: 1.48-6.79) showed a significantly higher risk of infection. Ethnicity was positively associated with the risk of developing COVID-19 (mutually adjusted OR = 2.15; 95% CI:1.12-4.11) in the multivariate analysis. Foreign women with COVID-19 were more likely to have a lower education level (p < 0.01), to be unemployed (p < 0.01), and to live in larger families (p < 0.01) compared to Italian pregnant women. CONCLUSIONS: The socioeconomic conditions described are characteristic of immigration patterns in our metropolitan area. These factors may increase the risk of viral transmission, reducing the effectiveness of lockdown and social distancing.

Caffeinated Coffee Consumption and Health Outcomes in the US Population: A Dose-Response Meta-Analysis and Estimation of Disease Cases and Deaths Avoided.

To explore the role of coffee on health outcomes in the United States, where coffee consumption is common, we conducted a meta-analysis of prospective studies investigating the magnitude (any compared with no consumption) and the dose-response shape (cups per day) of the associations between caffeinated coffee consumption and incidence/mortality of cardiovascular disease (CVD), as well as incidence of type 2 diabetes (T2D), hepatocellular carcinoma (HCC), endometrial cancer, melanoma, and nonmelanoma skin cancer. We selected the desirable health outcomes that have been shown to be positively associated with coffee consumption. Studies were identified by searching PubMed/Embase databases up to September 2019. Inclusion criteria included prospective studies that investigated the relation of ≥3 categories of caffeinated coffee consumption and the outcomes of interest. Twenty-six studies (42 distinct cohorts), with 93,706 cases/deaths and 3,713,932 participants, met the inclusion criteria. In any coffee consumers, there was a significant inverse association with the risk of CVD (RR = 0.90; 95% CI: 0.84, 0.96), T2D (RR = 0.90; 95% CI: 0.85, 0.96), endometrial cancer (RR = 0.85; 95% CI: 0.78, 0.92), melanoma (RR = 0.89; 95% CI: 0.80, 0.99), and nonmelanoma skin cancer (RR = 0.92; 95% CI: 0.89, 0.95). Coffee consumption was also inversely associated with HCC (RR = 0.93; 95% CI: 0.80, 1.08), without reaching statistical significance. The dose-response relation was nonlinear uniquely for CVD (P-nonlinearity = 0.01). In particular, the largest risk reduction was observed for 3-4 cups/d (∼120 mL/cup) and no reduction thereafter. For other outcomes, the risk decreased linearly over the whole coffee consumption range. Current patterns of consumption in the United States would account for a fraction of avoided cases/deaths ranging from 6% to 12% according to the outcome considered. This study confirms the beneficial health effects of caffeinated coffee consumption in the US population on the health outcomes considered, and quantifies their possible magnitude.