Q-Learning to navigate turbulence without a map.

We consider the problem of olfactory searches in a turbulent environment. We focus on agents that respond solely to odor stimuli, with no access to spatial perception nor prior information about the odor location. We ask whether navigation strategies to a target can be learned robustly within a sequential decision making framework. We develop a reinforcement learning algorithm using a small set of interpretable olfactory states and train it with realistic turbulent odor cues. By introducing a temporal memory, we demonstrate that two salient features of odor traces, discretized in few olfactory states, are sufficient to learn navigation in a realistic odor plume. Performance is dictated by the sparse nature of turbulent plumes. An optimal memory exists which ignores blanks within the plume and activates a recovery strategy outside the plume. We obtain the best performance by letting agents learn their recovery strategy and show that it is mostly casting cross wind, similar to behavior observed in flying insects. The optimal strategy is robust to substantial changes in the odor plumes, suggesting minor parameter tuning may be sufficient to adapt to different environments.

Healthcare professional views about a prehospital redirection pathway for stroke thrombectomy: a multiphase deductive qualitative study.

BACKGROUND: Mechanical thrombectomy for stroke is highly effective but time-critical. Delays are common because many patients require transfer between local hospitals and regional centres. A two-stage prehospital redirection pathway consisting of a simple ambulance screen followed by regional centre assessment to select patients for direct admission could optimise access. However, implementation might be challenged by the limited number of thrombectomy providers, a lack of prehospital diagnostic tests for selecting patients and whether finite resources can accommodate longer ambulance journeys plus greater central admissions. We undertook a three-phase, multiregional, qualitative study to obtain health professional views on the acceptability and feasibility of a new pathway. METHODS: Online focus groups/semistructured interviews were undertaken designed to capture important contextual influences. We purposively sampled NHS staff in four regions of England. Anonymised interview transcripts underwent deductive thematic analysis guided by the NASSS (Non-adoption, Abandonment and Challenges to Scale-up, Spread and Sustainability, Implementation) Implementation Science framework. RESULTS: Twenty-eight staff participated in 4 focus groups, 2 group interviews and 18 individual interviews across 4 Ambulance Trusts, 5 Hospital Trusts and 3 Integrated Stroke Delivery Networks (ISDNs). Five deductive themes were identified: (1) (suspected) stroke as a condition, (2) the pathway change, (3) the value participants placed on the proposed pathway, (4) the possible impact on NHS organisations/adopter systems and (5) the wider healthcare context. Participants perceived suspected stroke as a complex scenario. Most viewed the proposed new thrombectomy pathway as beneficial but potentially challenging to implement. Organisational concerns included staff shortages, increased workflow and bed capacity. Participants also reported wider socioeconomic issues impacting on their services contributing to concerns around the future implementation. CONCLUSIONS: Positive views from health professionals were expressed about the concept of a proposed pathway while raising key content and implementation challenges and useful 'real-world' issues for consideration.

Assessment of Anti-Inflammatory and Antioxidant Activities of a Proprietary Preparation of Quercetin-Rutin Blend (SophorOx™) in Exercised Rats.

Objectives: Flavonoids comprise a huge class of phenolic compounds widely distributed throughout the plant kingdom. Although quercetin and rutin have been studied individually for their therapeutic value, the synergistic effect of combining the two has previously not been measured. The objective of this trial was to evaluate the anti-inflammatory and antioxidant properties of both quercetin and rutin when combined in the form of SophorOx™ (a proprietary preparation of quercetin-rutin) in exercised rats. Methods: Sprague-Dawley rats were orally administered SophorOx™ at 500 mg·kg-1·b.w. and subjected to daily exercise on a fabricated treadmill for 4 weeks. A total of 24 animals were randomly divided into four groups. All the animals were examined for body weight, feed consumption, signs of clinical abnormalities, and morbidity. In addition, serum collected on days 8, 15, 22, and 29 were measured for the liver function test (LFT), random blood sugar (RBS), inflammatory markers C-reactive protein (CRP), oxidative stress markers (8-isoprostane (8-iso-PGF2α), malondialdehyde (MDA), 8-hydroxydeoxyguanosine (8-OHdG), and cytokine levels interleukin-1ß (IL-1ß), interleukin 6 (IL-6), and tumor necrosis factor-α (TNF-α)) by the ELISA method. Results: Rats that received SophorOx™ showed no signs of adverse effects, and no significant changes were observed in body weight, feed consumption, liver enzymes, and blood glucose levels. The exercise-treated rats administered with SophorOx™ exhibited a significant reduction in oxidative and inflammatory marker levels, viz., CRP (113.32 ng·mL-1) and oxidative stress markers 8-OHdG (19.32 pg·mL-1), MDA (1.06 nmol·mL-1), 8-iso-PGF2α (1.29 ng·mL-1), IL-1ß (0.77 pg·mL-1), and IL-6 (317.14 pg·mL-1) in comparison to those rodents that were exercised without SophorOx™. Conclusion: Oral administration of SophorOx™ significantly reduced oxidative stress and inflammatory marker levels when measured in the rodents subjected to high-intensity exercise.

The impact of large core and late treatment trials: An update on the modelled annual thrombectomy eligibility of UK stroke patients.

INTRODUCTION: To support decisions about thrombectomy provision, we have previously estimated the annual UK population eligible for treatment as ∼10% of stroke admissions. Since then, eight further randomised trials that could alter the eligibility rate have reported in 2021-23. We updated our estimates of the eligible population from these trials and other recent studies. PATIENTS AND METHODS: An updated decision tree describing the EVT eligible population for UK stroke admissions was produced. Decision criteria were derived from the highest level of evidence available. For nodes where no specific RCT data existed, evidence was obtained from the latest systematic review(s) or the highest quality observational data. RESULTS: We estimate that 15,420 (approximately 15%) of admitted UK stroke patients are now eligible for thrombectomy, or 14,930 if advanced brain imaging using MRI/CT perfusion or collateral assessment were used in all patients. This is a 54% increase in our previous estimate in 2021. Over 50% of LAO strokes are now potentially eligible for thrombectomy. The increase in eligibility is principally due to a much larger cohort of later presenting and/or larger ischaemic core patients. CONCLUSION: Most previously independent LAO stroke patients presenting within 24 h, even in the presence of a large ischaemic core on initial non-contrast CT, should be considered for thrombectomy with use of advanced brain imaging in those presenting beyond 12 h to identify salvageable penumbral brain tissue. Treatment in most patients remains critically time-dependent and our estimates should be interpreted with this in mind.

SCORE: a randomised controlled trial evaluating shared care (general practitioner and oncologist) follow-up compared to usual oncologist follow-up for survivors of colorectal cancer.

Background: SCORE is the first randomised controlled trial (RCT) to examine shared oncologist and general practitioner (GP) follow-up for survivors of colorectal cancer (CRC). SCORE aimed to show that shared care (SC) was non-inferior to usual care (UC) on the EORTC QLQ-C30 Global Health Status/Quality of Life (GHQ-QoL) scale to 12 months. Methods: The study recruited patients from five public hospitals in Melbourne, Australia between February 2017 and May 2021. Patients post curative intent treatment for stage I-III CRC underwent 1:1 randomisation to SC and UC. SC replaced two oncologist visits with GP visits and included a survivorship care plan and primary care management guidelines. Assessments were at baseline, 6 and 12 months. Difference between groups on GHQ-QoL to 12 months was estimated from a mixed model for repeated measures (MMRM), with a non-inferiority margin (NIM) of -10 points. Secondary endpoints included quality of life (QoL); patient perceptions of care; costs and clinical care processes (CEA tests, recurrences). Registration ACTRN12617000004369p. Findings: 150 consenting patients were randomised to SC (N = 74) or UC (N = 76); 11 GPs declined. The mean (SD) GHQ-QoL scores at 12 months were 72 (20.2) for SC versus 73 (17.2) for UC. The MMRM mean estimate of GHQ-QoL across the 6 month and 12 month follow-up was 69 for SC and 73 for UC, mean difference -4.0 (95% CI: -9.0 to 0.9). The lower limit of the 95% CI did not cross the NIM. There was no clear evidence of differences on other QoL, unmet needs or satisfaction scales. At 12 months, the majority preferred SC (40/63; 63%) in the SC group, with equal preference for SC (22/62; 35%) and specialist care (22/62; 35%) in UC group. CEA completion was higher in SC. Recurrences similar between arms. Patients in SC on average incurred USD314 less in health costs versus UC patients. Interpretation: SC seems to be an appropriate and cost-effective model of follow-up for CRC survivors. Funding: Victorian Cancer Agency and Cancer Australia.

Next-generation sequencing of pancreatic cyst wall specimens obtained using micro-forceps for improving diagnostic accuracy.

Background and study aims Pancreatic cysts are common incidental findings, with an estimated prevalence of 13% to 15% in imaging done for other reasons. Diagnosis often relies on collection of cyst fluid, but tissue sampling using micro-forceps may allow for a more reliable diagnosis and higher yield of DNA for next-generation sequencing (NGS). The primary aim was to assess the performance of NGS in identifying mucinous cyst. The secondary aims were to assess DNA yield between the cyst fluid and cyst wall tissue, complication rate and performance of conventional investigations. Patients and methods Twenty-four patients referred for endoscopic ultrasound were recruited. Biopsies were taken using micro-forceps and the AmpliSeq Cancer Hotspot panel was used for NGS, a polymerase chain reaction assay targeting several hotspots within 50 genes, including GNAS , KRAS and VHL . Results The concentration of DNA extracted from 24 cyst wall samples was significantly higher than in the nine of 24 available matched cyst fluid samples. The sensitivity, specificity, and diagnostic accuracy of NGS for diagnosing mucinous cyst were 93%, 50% and 84%; for standard of care, they were -66.6%, 50% and 63.1%; and for standard of care with NGS, they were 100%, 50%, and 89.4% respectively. Cyst wall biopsy was able to diagnose 19 of 24 cysts (4 high risk, 7 intraductal papillary mucinous neoplasms, 4 cysts of mucinous origin, and 4 benign). Conclusions NGS data correlate well with histology and may aid in diagnosis and risk stratification of pancreatic cysts. Cyst wall biopsy performs well in diagnosing cysts but was inadequate in five of 24 patients.

Impact of ERCP simulator training on early ERCP learning curves of novice trainees: a cohort study.

Background and study aim Simulator-based training has been extensively studied in training gastroduodenoscopy and colonoscopy and shown to significantly improve learning curves of novices. Data on simulator-based training in endoscopic retrograde cholangiopancreatography (ERCP) are scarce. We aimed to determine the impact of 2-day intensive hands-on simulator training on the course of the learning curve of novice trainees. Methods We conducted a prospective cohort study using a validated mechanical ERCP simulator (Boskoski-Costamagna ERCP Trainer). Six trainees were allocated to the simulation course program (SG). Each of these trainees were paired with an endoscopy trainee starting regular ERCP training at the same center who had no exposure to a simulation course program (control group; CG). The course included lectures, live ERCP demonstrations, and hands-on ERCP training to educate trainees in basic techniques related to cannulation, stent placement, stone extraction and stricture management. After the course, both the SG and CG started formal ERCP training in their respective centers. The Rotterdam Assessment Form for ERCP was used to register each performed ERCP. Simple moving average was applied to create learning curves based on successful common bile duct (CBD) cannulation. Outcomes were plotted against a historical cohort (HC). Results Thirteen trainees were included, six trainees in the SG and seven trainees in the CG, with a total of 717 ERCPs. Mean successful ERCP cannulation rate was higher for the simulator group at baseline compared to both CG and HC, 64% versus 43% and 42%, respectively. Differences became less explicit after 40 ERCPs, but persisted until a median of 75 ERCPs. Conclusions We demonstrate that 2-day hands-on simulator-based ERCP training course has a positive effect on the learning curves of ERCP trainees and should be considered an integral part of the training curricula for ERCP to develop skills prior to patient-based training.

What would other emergency stroke teams do? Using explainable machine learning to understand variation in thrombolysis practice.

INTRODUCTION: The aim of this work was to understand between-hospital variation in thrombolysis use among emergency stroke admissions in England and Wales. PATIENTS: A total of 88,928 patients who arrived at all 132 emergency stroke hospitals in England Wales within 4 h of stroke onset, from 2016 to 2018. METHODS: Machine learning was applied to the Sentinel Stroke National Audit Programme (SSNAP) data set, to learn which patients in each hospital would likely receive thrombolysis. We used XGBoost machine learning models, coupled with a SHAP model for explainability; Shapley (SHAP) values, providing estimates of how patient features, and hospital identity, influence the odds of receiving thrombolysis. RESULTS: Thrombolysis use in patients arriving within 4 h of known or estimated stroke onset ranged 7% -49% between hospitals. The odds of receiving thrombolysis reduced 9-fold over the first 120 min of arrival-to-scan time, varied 30-fold with stroke severity, reduced 3-fold with estimated rather than precise stroke onset time, fell 6-fold with increasing pre-stroke disability, fell 4-fold with onset during sleep, fell 5-fold with use of anticoagulants, fell 2-fold between 80 and 110 years of age, reduced 3-fold between 120 and 240 min of onset-to-arrival time and varied 13-fold between hospitals. The majority of between-hospital variance was explained by the hospital, rather than the differences in local patient populations. CONCLUSIONS: Using explainable machine learning, we identified that the majority of the between-hospital variation in thrombolysis use in England and Wales may be explained by differences in in-hospital processes and differences in attitudes to judging suitability for thrombolysis.

Effect of Broad-Spectrum Hemp Extract on Neurobehavioral Activity on the Immobilization Stress-Induced Model in Sprague Dawley Rats.

Background: Broad-spectrum hemp extract is expected to be a promising new intervention for managing stress and anxiety. Research has shown that the cannabinoids found in Cannabis sativa, such as cannabidiol (CBD), tetrahydrocannabinol (THC), and cannabigerol (CBG), possess anxiolytic properties that can positively impact mood and stress. Methods: In the current study, a broad-spectrum, nondetectable THC hemp extract with other minor cannabinoids (broad-spectrum hemp extract) was administered at 28 mg/kg·bw to evaluate its anxiolytic properties. This was performed using various behavioural models and biomarkers for oxidative stress. In addition, a 300 mg/kg·bw of Ashwagandha root extract was also incorporated to compare its effects on relieving stress and anxiety. Results: The decreased levels of lipid peroxidation were measured in broad-spectrum hemp extract (36 nmol/ml), Ashwagandha (37 nmol/ml), and induction control (49 nmol/ml) treated groups of animals. The levels of 2-AG decreased in the broad-spectrum hemp extract (1.5 ng/ml), Ashwagandha (1.2 ng/ml), and induction control (2.3 ng/ml) treated groups of animals. The levels of FAAH decreased in broad-spectrum hemp extract (1.6 ng/ml), Ashwagandha (1.7 ng/ml), and induction control (1.9 ng/ml) treated groups of animals. The levels of catalase increased in broad-spectrum hemp extract (35 ng/ml), Ashwagandha (37 ng/ml), and induction control (17 ng/ml) treated groups of animals. Similarly, increased levels of glutathione were found in broad-spectrum hemp extract (30 ng/ml), Ashwagandha (27 ng/ml), and induction control (16 ng/ml) treated groups of animals. Conclusion: Based on the results of this study, it can be concluded that broad-spectrum hemp extract inhibited the biomarkers for oxidative stress. Also, certain behavioural parameters showed improvements with respect to both the ingredient administered groups.

Soy and Gastrointestinal Health: A Review.

Soybean is the most economically important legume globally, providing a major source of plant protein for millions of people; it offers a high-quality, cost-competitive and versatile base-protein ingredient for plant-based meat alternatives. The health benefits of soybean and its constituents have largely been attributed to the actions of phytoestrogens, which are present at high levels. Additionally, consumption of soy-based foods may also modulate gastrointestinal (GI) health, in particular colorectal cancer risk, via effects on the composition and metabolic activity of the GI microbiome. The aim of this narrative review was to critically evaluate the emerging evidence from clinical trials, observational studies and animal trials relating to the effects of consuming soybeans, soy-based products and the key constituents of soybeans (isoflavones, soy proteins and oligosaccharides) on measures of GI health. Our review suggests that there are consistent favourable changes in measures of GI health for some soy foods, such as fermented rather than unfermented soy milk, and for those individuals with a microbiome that can metabolise equol. However, as consumption of foods containing soy protein isolates and textured soy proteins increases, further clinical evidence is needed to understand whether these foods elicit similar or additional functional effects on GI health.

A case of idiopathic chylous ascites.

Chylous ascites is a rare condition found in 1 in 20 000 patients admitted to hospital with abdominal distention. It is caused by a limited number of pathologies but can, in rare situations, be idiopathic. Its management is difficult and usually involves correcting the primary pathology, making idiopathic chylous ascites particularly difficult to manage. We present a case of idiopathic chylous ascites extensively investigated over a period of several years. An incidental finding of B cell lymphoma was initially suspected to have been the primary cause of the ascites; however, after successful treatment of this condition, the patient's ascites did not resolve. Diagnostic difficulties and management are discussed and an overview of the diagnostic process is outlined through this case.

Comparing magnetic resonance liver fat fraction measurements with histology in fibrosis: the difference between proton density fat fraction and tissue mass fat fraction.

OBJECTIVE: Magnetic resonance spectroscopy (MRS) provides a powerful method of measuring fat fraction. However, previous studies have shown that MRS results give lower values compared with visual estimates from biopsies in fibrotic livers. This study investigated these discrepancies and considered whether a tissue water content correction, as assessed by MRI relaxometry, could provide better agreement. MATERIALS AND METHODS: 110 patients were scanned in a 1.5 T Philips scanner and biopsies were obtained. Multiple echo MRS (30 × 30 × 30 mm volume) was used to determine Proton Density Fat Fraction (PDFF). Biopsies were assessed by visual assessment for fibrosis and steatosis grading. Digital image analysis (DIA) was also used to quantify fat fraction within tissue samples. T1 relaxation times were then used to estimate tissue water content to correct PDFF for confounding factors. RESULTS: PDFF values across the four visually assessed steatosis grades were significantly less in the higher fibrosis group (F3-F4) compared to the lower fibrosis group (F0-F2). The slope of the linear regression of PDFF vs DIA fat fraction was ~ 1 in the low fibrosis group and 0.77 in the high fibrosis group. Correcting for water content based on T1 increased the gradient but it did not reach unity. DISCUSSION: In fibrotic livers, PDFF underestimated fat fraction compared to DIA methods. Values were improved by applying a water content correction, but fat fractions were still underestimated.

Association between time to treatment and clinical outcomes in endovascular thrombectomy beyond 6 hours without advanced imaging selection.

BACKGROUND: The effectiveness and safety of endovascular thrombectomy (EVT) in the late window (6-24 hours) for acute ischemic stroke (AIS) patients selected without advanced imaging is undetermined. We aimed to assess clinical outcomes and the relationship with time-to-EVT treatment beyond 6 hours of stroke onset without advanced neuroimaging. METHODS: Patients who underwent EVT selected with non-contrast CT/CT angiography (without CT perfusion or MR imaging), between October 2015 and March 2020, were included from a national stroke registry. Functional and safety outcomes were assessed in both early (<6 hours) and late windows with time analyzed as a continuous variable. RESULTS: Among 3278 patients, 2610 (79.6%) and 668 (20.4%) patients were included in the early and late windows, respectively. In the late window, for every hour delay, there was no significant association with shift towards poorer functional outcome (modified Rankin Scale (mRS)) at discharge (adjusted common OR 0.98, 95% CI 0.94 to 1.01, p=0.27) or change in predicted functional independence (mRS ≤2) (24.5% to 23.3% from 6 to 24 hours; aOR 0.99, 95% CI0.94 to 1.04, p=0.85). In contrast, predicted functional independence was time sensitive in the early window: 5.2% reduction per-hour delay (49.4% to 23.5% from 1 to 6 hours, p=0.0001). There were similar rates of symptomatic intracranial hemorrhage (sICH) (3.4% vs 4.6%, p=0.54) and in-hospital mortality (12.9% vs 14.6%, p=0.33) in the early and late windows, respectively, without a significant association with time. CONCLUSION: In this real-world study, there was minimal change in functional disability, sICH and in-hospital mortality within and across the late window. While confirmatory randomized trials are needed, these findings suggest that EVT remains feasible and safe when performed in AIS patients selected without advanced neuroimaging between 6-24 hours from stroke onset.

Endovascular thrombectomy beyond 24 hours from ischemic stroke onset: a propensity score matched cohort study.

BACKGROUND: The safety and functional outcome of endovascular thrombectomy (EVT) in the very late (VL; >24 hours) time window from ischemic stroke onset remains undetermined. METHODS: Using data from a national stroke registry, we used propensity score matched (PSM) individual level data of patients who underwent EVT, selected with CT perfusion or non-contrast CT/CT angiography, between October 2015 and March 2020. Functional and safety outcomes were assessed in both late (6-24 hours) and VL time windows. Subgroup analysis was performed of imaging selection modality in the VL time window. RESULTS: We included 1150 patients (late window: 1046 (208 after PSM); VL window: 104 (104 after PSM)). Compared with EVT treatment initiation between 6 and 24 hours, patients treated in the VL window had similar modified Rankin Scale (mRS) scores at discharge (ordinal shift; common OR=1.08, 95% CI 0.69 to 1.47, p=0.70). No significant differences in achieving good functional outcome (mRS ≤2 at discharge; 28.8% (VL) vs 29.3% (late), OR=0.97, 95% CI 0.58 to 1.64, p=0.93), successful reperfusion (modified Thrombolysis in Cerebral Infarction score of 2b-3) (p=0.77), or safety outcomes of symptomatic intracranial hemorrhage (p=0.43) and inhospital mortality (p=0.23) were demonstrated. In the VL window, there was no significant difference in functional outcome among patients selected with perfusion versus those selected without perfusion imaging (common OR=1.38, 95% CI 0.81 to 1.76, p=0.18). CONCLUSION: In this real world study, EVT beyond 24 hours from stroke onset or last known well appeared to be feasible, with comparable safety and functional outcomes to EVT initiation between 6 and 24 hours. Randomized trials assessing the efficacy of EVT in the VL window are warranted, but may only be feasible with a large international collaborative approach.

Association between anesthesia modality and clinical outcomes following endovascular stroke treatment in the extended time window.

BACKGROUND: There is a paucity of data on anesthesia-related outcomes for endovascular treatment (EVT) in the extended window (>6 hours from ischemic stroke onset). We compared functional and safety outcomes between local anesthesia (LA) without sedation, conscious sedation (CS) and general anesthesia (GA). METHODS: Patients who underwent EVT in the early (<6 hours) and extended time windows using LA, CS, or GA between October 2015 and March 2020 were included from a UK national stroke registry. Multivariable analyses were performed, adjusted for age, sex, baseline stroke severity, pre-stroke disability, EVT technique, center, procedural time and IV thrombolysis. RESULTS: A total of 4337 patients were included, 3193 in the early window (1135 LA, 446 CS, 1612 GA) and 1144 in the extended window (357 LA, 134 CS, 653 GA). Compared with GA, patients treated under LA alone had increased odds of an improved modified Rankin Scale (mRS) score at discharge (early: adjusted common (ac) OR=1.50, 95% CI 1.29 to 1.74, p=0.001; extended: acOR=1.29, 95% CI 1.01 to 1.66, p=0.043). Similar mRS scores at discharge were found in the LA and CS cohorts in the early and extended windows (p=0.21). Compared with CS, use of GA was associated with a worse mRS score at discharge in the early window (acOR=0.73, 95% CI 0.45 to 0.96, p=0.017) but not in the extended window (p=0.55). There were no significant differences in the rates of symptomatic intracranial hemorrhage or in-hospital mortality across the anesthesia modalities in the extended window. CONCLUSION: LA without sedation during EVT was associated with improved functional outcomes compared with GA, but not CS, within and beyond 6 hours from stroke onset. Prospective studies assessing anesthesia-related outcomes in the extended time window are warranted.

Avocado Consumption and Cardiometabolic Health: A Systematic Review and Meta-Analysis.

BACKGROUND: Avocados are a rich source of unsaturated fats and bioactives, however, their role in altering cardiometabolic risk factors is unclear. OBJECTIVE: The aim was to review the effects of consuming diets containing avocado compared with control diets containing no or low amounts of avocado on cardiometabolic risk factors in adults who were healthy, had clinical cardiovascular disease, or were at increased risk of cardiovascular disease. METHODS: Five electronic databases were searched (PubMed, Web of Science, Scopus, ProQuest, and a Clinical Trials Registry) along with Google Scholar to identify studies published between January 1990 and November 10, 2021. Randomized controlled trials ≥3 weeks and prospective cohort studies were included. Ten studies-9 randomized controlled trials (n = 503 participants) and 1 prospective observational study (n = 55,407)-met the inclusion criteria. Outcomes assessed by means of meta-analysis were low-density lipoprotein cholesterol (LDL-C) (primary), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), and triglycerides. Outcomes assessed by narrative review were TC to HDL-C ratio, non-HDL-C, apolipoprotein B, blood pressure, body weight, body mass index (calculated as kg/m2), waist circumference, waist-to-hip ratio, body composition, and blood glucose and insulin concentrations. Risk of bias was assessed using the Cochrane Risk of Bias tool, version 2.0 and Newcastle-Ottawa Scale; quality of evidence was examined using the Grading of Recommendations, Assessment, Development and Evaluation method. Random-effects models meta-analyses were performed when there were ≥3 studies of the same design (ie, randomized controlled trial) and reporting the same outcome. Statistical heterogeneity was assessed by calculating χ2 and I2 statistics and publication bias was assessed by funnel plots. RESULTS: Overall, there was a small, significant reduction in TC (-5.08 mg/dL [to convert to mmol/L, divide by 38.67]; 95% CI -9.29 to -0.87 mg/dL; P = .02) in avocado vs the control groups and no significant difference in LDL-C, HDL-C, or triglycerides. Subgroup analysis demonstrated significant reductions in LDL-C (-9.4 mg/dL [to convert to mmol/L, divide by 38.67]; 95% CI -10.84 to -7.95 mg/dL; P < .00001) and TC (-7.54 mg/dL; 95% CI -9.40 to -5.68 mg/dL; P < .00001) in avocado vs control groups in hypercholesterolemic populations, and no differences were seen in normocholesterolemic populations. However, the certainty in the findings was graded as low to very low. Body weight and composition were not negatively affected by avocado consumption. CONCLUSIONS: Avocado consumption may reduce TC and LDL-C in people with hypercholesterolemia. Avocado consumption does not negatively impact body weight. Larger, well-conducted studies are needed to have greater confidence in the role of avocado consumption on cardiovascular disease risk factors.

Environmental sustainability in national food-based dietary guidelines: a global review.

Food-based dietary guidelines (FBDGs) provide country-specific guidance on what constitutes a healthy diet. With increasing evidence for the synergy between human and planetary health, FBDGs have started to consider the environmental sustainability of food choices. However, the number of countries that discuss environmental sustainability in their guidelines is unknown. The purpose of this Review was to identify countries with government-endorsed FBDGs that made explicit mention of environmental sustainability and to examine the breadth and depth of the inclusion of sustainability in FBDGs. The Food and Agriculture Organization of the UN identified 95 countries with FBDGs. We assessed 83 countries against our inclusion criteria, of which 37 mentioned environmental sustainability. Relevant content was assessed against a set of criteria based on the Food and Agriculture Organization's guiding principles for sustainable healthy diets. The depth to which environmental sustainability was discussed varied and it was often restricted to general explanations of what a sustainable diet is. Few FBDGs addressed why sustainability is important, how dietary changes can be made, or provided quantified advice for implementing sustainable diets.