Impact of mediterranean diet promotion on environmental sustainability: a longitudinal analysis

OBJECTIVE

This article aims to estimate the differences in environmental impact (greenhouse gas [GHG] emissions, land use, energy used, acidification and potential eutrophication) after one year of promoting a Mediterranean diet (MD).

METHODS

Baseline and 1-year follow-up data from 5800 participants in the PREDIMED-Plus study were used. Each participant's food intake was estimated using validated semi-quantitative food frequency questionnaires, and the adherence to MD using the Dietary Score. The influence of diet on environmental impact was assessed through the EAT-Lancet Commission tables. The influence of diet on environmental impact was assessed through the EAT-Lancet Commission tables. The association between MD adherence and its environmental impact was calculated using adjusted multivariate linear regression models.

RESULTS

After one year of intervention, the kcal/day consumed was significantly reduced (-125,1 kcal/day), adherence to a MD pattern was improved (+0,9) and the environmental impact due to the diet was significantly reduced (GHG: -361 g/CO2-eq; Acidification:-11,5 g SO2-eq; Eutrophication:-4,7 g PO4-eq; Energy use:-842,7 kJ; and Land use:-2,2 m2). Higher adherence to MD (high vs. low) was significantly associated with lower environmental impact both at baseline and one year follow-up. Meat products had the greatest environmental impact in all the factors analysed, both at baseline and at one-year follow-up, in spite of the reduction observed in their consumption.

CONCLUSIONS

A program promoting a MD, after one year of intervention, significantly reduced the environmental impact in all the factors analysed. Meat products had the greatest environmental impact in all the dimensions analysed.

Effect of a nutritional intervention based on an energy-reduced Mediterranean diet on environmental impact

OBJECTIVE

To estimate the environmental impact of a dietary intervention based on an energy-reduced Mediterranean diet (MedDiet) after one year of follow-up.

METHODS

Baseline and 1-year follow-up data were used for 5800 participants aged 55-75 years with metabolic syndrome in the PREDIMED-Plus study. Food intake was estimated through a validated semiquantitative food consumption frequency questionnaire, and adherence to the MedDiet was estimated through the Diet Score. Using the EAT-Lancet Commission tables we assessed the influence of dietary intake on environmental impact (through five indicators: greenhouse gas emissions (GHG), land use, energy used, acidification and potential eutrophication). Using multivariable linear regression models, the association between the intervention and changes in each of the environmental factors was assessed. Mediation analyses were carried out to estimate to what extent changes in each of 2 components of the intervention, namely adherence to the MedDiet and caloric reduction, were responsible for the observed reductions in environmental impact.

RESULTS

We observed a significant reduction in the intervention group compared to the control group in acidification levels (-13.3 vs. -9.9 g SO2-eq), eutrophication (-5.4 vs. -4.0 g PO4-eq) and land use (-2.7 vs. -1.8 m2). Adherence to the MedDiet partially mediated the association between intervention and reduction of acidification by 15 %, eutrophication by 10 % and land use by 10 %. Caloric reduction partially mediated the association with the same factors by 55 %, 51 % and 38 % respectively. In addition, adherence to the MedDiet fully mediated the association between intervention and reduction in GHG emissions by 56 % and energy use by 53 %.

CONCLUSIONS

A nutritional intervention based on consumption of an energy-reduced MedDiet for one year was associated with an improvement in different environmental quality parameters.

[Ethics of care: Assessment of the ethical issues in the protocols or consensuses on mechanical restraint in force in Spain]

INTRODUCTION

Mechanical restraints are widely used in health care practice, despite the numerous ethical conflicts they raise. The aim of this study is to evaluate the ethical considerations contemplated in the current protocols on mechanical restraint in Spain.

METHOD

Systematic review in PubMed, WOS and Scopus, Google and Google Scholar. An ad hoc list of 30 items was used to evaluate the ethical content of the protocols. The quality of guidelines was assessed with AGREE II.

RESULTS

The need for informed consent (IC) is reflected in 72% of the documents, the IC model sheet is included in only 41% of them, the rest of the analyzed characteristics on IC are fulfilled in percentages between 6% (the document includes the need to reevaluate the indication for IC) and 31% (the document contemplates to whom it should be requested). More than 20 ethical contents are reflected in 31% of them and less than 10 in 19% of the guidelines. The quality of the guides, according to AGREE II, ranged from 27 to 116 points (maximum possible 161), with a mean score of 68.7. Only 9% of the documents were classified as high quality. Finally, the correlation between ethical content and quality measured with AGREE II was 0.75.

CONCLUSIONS

The variability of ethical contents in guidelines on mechanical restraints is very high. The ethical requirements to be included in protocols, consensus or Clinical Practice Guidelines should be defined.

Post-publication research integrity concerns in randomized clinical trials: A scoping review of the literature

BACKGROUND

Post-publication handling of integrity concerns in randomized clinical trials (RCTs) is a contentious matter.

OBJECTIVES

We undertook a scoping systematic review to map the literature regarding post-publication integrity issues in RCTs.

SEARCH STRATEGY AND SELECTION CRITERIA

Following prospective registration (https://osf.io/pgxd8) we initially searched PubMed and Scopus but subsequently extended it to include the Cochrane Library, and Google Scholar databases without language, article type or publication time restriction until November 2022. Reviewers independently selected published articles covering any aspect of post-publication research integrity concerns in RCTs.

DATA COLLECTION AND ANALYSIS

The study findings grouped within domains relating to issues concerning post-publication integrity were extracted in duplicate, verified by a third reviewer, and then tabulated.

MAIN RESULTS

The initial search captured 3159 citations, of which 89 studies were included in the review. Cross-sectional studies constituted the majority of included studies (n = 34, 38.2%), followed by systematic reviews (n = 10, 11.2%), methodology reviews/studies (n = 9, 10.1%) and other types of descriptive studies (n = 8, 9.0%). A total of 21 articles (23.6%) covered the domain on general issues, 25 (28.1%) in the journal's instructions and policies domain, eight (9.0%) in the editorial and peer review domain, one (1.1%) in the correspondence and complaints (post-publication peer review) domain, 12 (13.5%) in the investigation for concerns domain, six (6.7%) in the post-investigation decisions and sanctions domain, none in the critical appraisal guidance domain, five (5.6%) in the integrity assessment in systematic reviews domain, and 26 (29.2%) in the recommendations for future research domain. A total of 12 of the selected articles (13.5%) covered two (n = 9) or three (n = 3) different domains.

CONCLUSIONS

Various research integrity domains and issues covering post-publication aspects of RCT integrity were captured and gaps were identified, mostly related with the necessary implications for all stakeholders to improve research transparency. There is an urgent need for a multistakeholder consensus towards creating specific statements for addressing post-publication integrity concerns in RCTs.

Dietary intake of Perfluorooctanesulfonic acid (PFOS) and glucose homeostasis parameters in a non-diabetic senior population

BACKGROUND

Endocrine disruptors (EDs) have emerged as potential contributors to the development of type-2 diabetes. Perfluorooctane sulfonate (PFOS), is one of these EDs linked with chronic diseases and gathered attention due to its widespread in food.

OBJECTIVE

To assess at baseline and after 1-year of follow-up associations between estimated dietary intake (DI) of PFOS, and glucose homeostasis parameters and body-mass-index (BMI) in a senior population of 4600 non-diabetic participants from the PREDIMED-plus study.

METHODS

Multivariable linear regression models were conducted to assess associations between baseline PFOS-DI at lower bound (LB) and upper bound (UB) established by the EFSA, glucose homeostasis parameters and BMI.

RESULTS

Compared to those in the lowest tertile, participants in the highest tertile of baseline PFOS-DI in LB and UB showed higher levels of HbA1c [β-coefficient(CI)] [0.01 %(0.002 to 0.026), and [0.06 mg/dL(0.026 to 0.087), both p-trend ≤ 0.001], and fasting plasma glucose in the LB PFOS-DI [1.05 mg/dL(0.050 to 2.046),p-trend = 0.022]. Prospectively, a positive association between LB of PFOS-DI and BMI [0.06 kg/m2(0.014 to 0.106) per 1-SD increment of energy-adjusted PFOS-DI was shown. Participants in the top tertile showed an increase in HOMA-IR [0.06(0.016 to 0.097), p-trend = 0.005] compared to participants in the reference tertile after 1-year of follow-up.

DISCUSSION

This is the first study to explore the association between DI of PFOS and glucose homeostasis. In this study, a high baseline DI of PFOS was associated with a higher levels of fasting plasma glucose and HbA1c and with an increase in HOMA-IR and BMI after 1-year of follow-up.

Association between Beverage Consumption and Environmental Sustainability in an Adult Population with Metabolic Syndrome

Beverages are an important part of the diet, but their environmental impact has been scarcely assessed. The aim of this study was to assess how changes in beverage consumption over a one-year period can impact the environmental sustainability of the diet. This is a one-year longitudinal study of 55-75-year-old participants with metabolic syndrome (n = 1122) within the frame of the PREDIMED-Plus study. Food and beverage intake were assessed using a validated food frequency questionnaire and a validated beverage-specific questionnaire. The Agribalyse® 3.0.1 database was used to calculate environmental impact parameters such as greenhouse gas emission, energy, water, and land use. A sustainability beverage score was created by considering the evaluated environmental markers. A higher beverage sustainability score was obtained when decreasing the consumption of bottled water, natural and packed fruit juice, milk, and drinkable dairy, soups and broths, sorbets and jellies, soft drinks, tea without sugar, beer (with and without alcohol), and wine, as well as when increasing the consumption of tap water and coffee with milk and without sugar. Beverage consumption should be considered when assessing the environmental impact of a diet. Trial registration: ISRCTN, ISRCTN89898870. Registered 5 September 2013.

Coronavirus disease 2019 is associated with long-term depressive symptoms in Spanish older adults with overweight/obesity and metabolic syndrome

BACKGROUND

The coronavirus disease 2019 (COVID-19) has serious physiological and psychological consequences. The long-term (>12 weeks post-infection) impact of COVID-19 on mental health, specifically in older adults, is unclear. We longitudinally assessed the association of COVID-19 with depression symptomatology in community-dwelling older adults with metabolic syndrome within the framework of the PREDIMED-Plus cohort.

METHODS

Participants (n = 5486) aged 55-75 years were included in this longitudinal cohort. COVID-19 status (positive/negative) determined by tests (e.g. polymerase chain reaction severe acute respiratory syndrome coronavirus 2, IgG) was confirmed via event adjudication (410 cases). Pre- and post-COVID-19 depressive symptomatology was ascertained from annual assessments conducted using a validated 21-item Spanish Beck Depression Inventory-II (BDI-II). Multivariable linear and logistic regression models assessed the association between COVID-19 and depression symptomatology.

RESULTS

COVID-19 in older adults was associated with higher post-COVID-19 BDI-II scores measured at a median (interquartile range) of 29 (15-40) weeks post-infection [fully adjusted β = 0.65 points, 95% confidence interval (CI) 0.15-1.15; p = 0.011]. This association was particularly prominent in women (β = 1.38 points, 95% CI 0.44-2.33, p = 0.004). COVID-19 was associated with 62% increased odds of elevated depression risk (BDI-II ≥ 14) post-COVID-19 when adjusted for confounders (odds ratio; 95% CI 1.13-2.30, p = 0.008).

CONCLUSIONS

COVID-19 was associated with long-term depression risk in older adults with overweight/obesity and metabolic syndrome, particularly in women. Thus, long-term evaluations of the impact of COVID-19 on mental health and preventive public health initiatives are warranted in older adults.

Lifestyle Interventions in an Aged Population: Challenges and Opportunities from a Public Health Perspective

In recent decades, the prevalence of non-communicable diseases (NCDs) such as obesity, type 2 diabetes mellitus, cancer and cardiovascular disease has increased worldwide [...].

Microbial Phenolic Metabolites Are Associated with Improved Cognitive Health

SCOPE

Diets rich in polyphenols has been associated with better cognitive performance. The aim of this study is to assess the relationship between microbial phenolic metabolites (MPM) in urine and cognition in the context of an older population at high cardiovascular risk.

METHODS AND RESULTS

A cross-sectional analysis is conducted in 400 individuals of the PREDIMED-Plus study. Liquid chromatography coupled to mass spectrometry is used to identify urinary MPM. Mediterranean diet (MedDiet) adherence is estimated with a 17-item questionnaire and cognitive function is evaluated with a battery of neuropsychological tests. Multivariable-adjusted linear regression models are fitted to assess the relationship of urinary MPM with the MedDiet and cognitive tests. Protocatechuic acid and enterolactone glucuronide are associated with higher adherence to the MedDiet. Regarding cognitive function, protocatechuic acid, vanillic acid glucuronide, 3-hydroxybenzoic acid, enterodiol glucuronide, and enterolactone glucuronide are directly associated with a global composite score of all the cognitive tests. Furthermore, protocatechuic acid and enterolactone glucuronide are associated with higher scores in the Mini-Mental State Examination, whereas enterodiol glucuronide is associated with improved Clock Drawing Test scores.

CONCLUSIONS

These results suggest that the MedDiet is linked to MPM associated with better cognitive performance in an older population.

Quality indicators for the diagnosis and treatment of breast cancer integrated assistance: A critical appraisal

INTRODUCTION

Quality indicators (QIs) are essential for adequate control of the health care management process, recognizing areas of improvement and providing solutions. We aimed to evaluate the Integrated Breast Cancer (BC) Care Process QIs.

METHODS

We studied 487 consecutive BC cases diagnosed from November 1st, 2013, to November 30th, 2019, in a Spanish healthcare area, and we estimated the associated QIs.

RESULTS

Four indicators did not meet the standards and were analysed based on related sociodemographic and clinical variables. The surgical delay after a multidisciplinary team discussion (mean 64%, IQR 59.6-68.5) was lower in elder people (p=0.027), and early histological grades (p=0.019) and stages (p=0.008). The adjuvant treatment delay (mean 55.7%, IQR 51.1-60.3) was lower in advance stages (p=0.002) and when there was no reoperation (p=0.001). The surgical delay after inclusion (mean 83.2%, IQR 79.3-87.2) was lower in early histological grades (p=0.048). The immediate reconstruction (mean 42.3%, IQR 34.0-50.5) reached 72.3% in young women compared to 11.8% in older than 70 years (p=0.001) and it was higher in early stages (45.3% vs 36.2%; p=0.049).

CONCLUSION

The study of QIs evaluated their compliance and analysed the variables influencing them to propose improvement measures. Not all the indicators were equally valuable. Some depended on the available resources, and others on the mix of patients or complementary treatments. It would be essential to identify the specific target populations to estimate the indicators or provide standards stratified by the related variables.

Dietary Iron, Anemia Markers, Cognition, and Quality of Life in Older Community-Dwelling Subjects at High Cardiovascular Risk

Anemia causes hypo-oxygenation in the brain, which could lead to cognitive disorders. We examined dietary iron intake as well as anemia markers (i.e., hemoglobin, hematocrit, mean corpuscular volume) and diabetes coexistence in relation to neuropsychological function and quality of life. In this study, 6117 community-dwelling adults aged 55-75 years (men) and 60-75 years (women) with overweight/obesity and metabolic syndrome were involved. We performed the Mini-Mental State Examination (MMSE), the Trail Making Test parts A and B (TMT-A/B), Semantic Verbal Fluency of animals (VFT-a), Phonological Verbal Fluency of letter P (VFT-p), Digit Span Test (DST), the Clock Drawing Test (CDT), and the Short Form-36 Health Survey (SF36-HRQL test). Dietary iron intake did not influence neuropsychological function or quality of life. However, anemia and lower levels of anemia markers were associated with worse scores in all neurophysiological and SF36-HRQL tests overall, but were especially clear in the MMSE, TMT-B (cognitive flexibility), and the physical component of the SF36-HRQL test. The relationships between anemia and diminished performance in the TMT-A/B and VFT tasks were notably pronounced and statistically significant solely among participants with diabetes. In brief, anemia and reduced levels of anemia markers were linked to inferior cognitive function, worse scores in different domains of executive function, as well as a poorer physical, but not mental, component of quality of life. It was also suggested that the coexistence of diabetes in anemic patients may exacerbate this negative impact on cognition. Nevertheless, dietary iron intake showed no correlation with any of the outcomes. To make conclusive recommendations for clinical practice, our findings need to be thoroughly tested through methodologically rigorous studies that minimize the risk of reverse causality.

Association of adiposity and its changes over time with COVID-19 risk in older adults with overweight/obesity and metabolic syndrome: a longitudinal evaluation in the PREDIMED-Plus cohort

BACKGROUND

Cross-sectionally, older age and obesity are associated with increased coronavirus disease-2019 (COVID-19) risk. We assessed the longitudinal associations of baseline and changes in adiposity parameters with COVID-19 incidence in older adults at high cardiovascular risk.

METHODS

This analysis included 6874 men and women (aged 55-75 years) with overweight/obesity and metabolic syndrome in the PREDIMED-Plus lifestyle intervention trial for cardiovascular risk reduction. Body weight, body-mass-index (BMI), waist circumference, waist-to-height ratio (WHtR), and a body shape index (ABSI) were measured at baseline and annual follow-up visits. COVID-19 was ascertained by an independent Event Committee until 31 December 2021. Cox regression models were fitted to evaluate the risk of COVID-19 incidence based on baseline adiposity parameters measured 5-6 years before the pandemic and their changes at the visit prior to censoring.

RESULTS

At the time of censoring, 653 incident COVID-19 cases occurred. Higher baseline body weight, BMI, waist circumference, and WHtR were associated with increased COVID-19 risk. During the follow-up, every unit increase in body weight (HRadj (95%CI): 1.01 (1.00, 1.03)) and BMI (HRadj: 1.04 (1.003, 1.08)) was associated with increased COVID-19 risk.

CONCLUSIONS

In older adults with overweight/obesity, clinically significant weight loss may protect against COVID-19.

TRIAL REGISTRATION

This study is registered at the International Standard Randomized Controlled Trial (ISRCT; http://www.isrctn.com/ISRCTN89898870 ).

Design of a safety round model for intensive care units

INTRODUCTION

Safety Rounds (SR) are an operational tool that allow knowing adherence to good practices, help identify risks and incidents in patient safety (PS), allowing improvement actions to be implemented. The objective of this work was the design of a procedure to perform SR in an Intensive Care Unit (ICU).

METHODS

Preparation of a checklist for the development of SR in the ICU through the nominal group technique, with the participation of managers, middle managers and professionals from different disciplines and categories. In the first place, a group of experts agreed, based on the recommendations on good practices in PS, the definition of items, their coding, the criteria for compliance and the impact of non-compliance. Subsequently, its viability was determined through a cross-sectional study through the piloting of two SRs to adjust the items in real clinical practice conditions.

RESULTS

A specific SR model for ICUs has been obtained through a checklist. The group of experts prepared a first list made up of 39 items of 6 essential dimensions and defined the method of implementation. Mean time to complete the two SRs was 85 min, including the briefing and subsequent debriefing. After the validation pilot, the dimensions were reduced to 5, 3 items were deleted, 2 items were transferred to another dimension and 3 items related to nosocomial infections and informed consent were modified. In addition, the data sources, the compliance criteria and their relative weight were redefined. The final list was considered useful and relevant to improve practice.

CONCLUSIONS

Through a consensus methodology, a checklist has been built to be used in the RS of an ICU. This model can serve as a basis for its use in healthcare services with similar characteristics.

Colorectal cancer treatment guidelines and shared decision making quality and reporting assessment: Systematic review

INTRODUCTION

Physicians must share decisions and choose personalised treatments regarding patients´ beliefs and values.

OBJECTIVE

To analyse the quality of the recommendations about shared decision making (SDM) in colorectal (CRC) and anal cancer treatment clinical practice guidelines (CPGs) and consensus statements (CSs).

METHODS

Guidelines were systematically reviewed following prospective registration (Prospero: CRD42021286146) without language restrictions searching 15 databases and 59 professional society websites from January 2010 to November 2021. A validated 31-item SDM quality assessment tool was employed to extract data in duplicate.

RESULTS

We identified 134 guidelines. Only 46/134 (34.3 %) mentioned SDM. Fifteen (11.1 %) made clear, precise and actionable recommendations, while 9/134 (6.7 %) indicated the strength of the SDM-related recommendations. CPGs underpinned by systematic reviews reported SDM more often than those based on consensus or reviews (35.9 % vs 32.0 %; p = 0.031). Guidelines that reported following quality tools (i.e., AGREE II) more commonly commented about SDM than when it was not reported (75.0 % vs 32.0 %; p = 0.003).

CONCLUSION AND PRACTICE IMPLICATIONS

Most of the CRC and anal treatment guidelines did not mention SDM and it was superficial. Guidelines based on systematic reviews and those using quality tools demonstrated better reporting of SDM. Recommendations about SDM in these guidelines merit urgent improvement.

Research integrity in randomized clinical trials: A scoping umbrella review

BACKGROUND

Randomized clinical trials (RCTs) are experiencing a crisis of confidence in their trustworthiness. Although a comprehensive literature search yielded several reviews on RCT integrity, an overarching overview is lacking.

OBJECTIVES

The authors undertook a scoping umbrella review of the research integrity literature concerning RCTs.

SEARCH STRATEGY AND SELECTION CRITERIA

Following prospective registration (https://osf.io/3ursn), two reviewers independently searched PubMed, Scopus, The Cochrane Library, and Google Scholar, without language or time restrictions, until November 2021. The authors included systematic reviews covering any aspect of research integrity throughout the RCT lifecycle.

DATA COLLECTION AND ANALYSIS

The authors assessed methodological quality using a modified AMSTAR 2 (A Measurement Tool to Assess Systematic Reviews) tool and collated the main findings.

MAIN RESULTS

A total of 55 relevant reviews, summarizing 6001 studies (median per review, 63; range, 8-1106) from 1964 to 2021, had an overall critically low quality of 96% (53 reviews). Topics covered included general aspects (15%), design and approval (22%), conduct and monitoring (11%), reporting (38%), postpublication concerns (2%), and future research (13%). The most common integrity issues covered were ethics (18%) and transparency (18%).

CONCLUSIONS

Low-quality reviews identified various integrity issues across the RCT lifecycle, emphasizing the importance of high ethical standards and professionalism while highlighting gaps in the integrity landscape. Multistakeholder consensus is needed to develop specific RCT integrity standards.

Assessing the Integrity of Clinical Trials Included in Evidence Syntheses

Evidence syntheses of randomized clinical trials (RCTs) offer the highest level of scientific evidence for informing clinical practice and policy. The value of evidence synthesis itself depends on the trustworthiness of the included RCTs. The rising number of retractions and expressions of concern about the authenticity of RCTs has raised awareness about the existence of problematic studies, sometimes called "zombie" trials. Research integrity, i.e., adherence to ethical and professional standards, is a multi-dimensional concept that is incompletely evaluated for the RCTs included in current evidence syntheses. Systematic reviewers tend to rely on the editorial and peer-review system established by journals as custodians of integrity of the RCTs they synthesize. It is now well established that falsified and fabricated RCTs are slipping through. Thus, RCT integrity assessment becomes a necessary step in systematic reviews going forward, in particular because RCTs with data-related integrity concerns remain available for use in evidence syntheses. There is a need for validated tools for systematic reviewers to proactively deploy in the assessment of integrity deviations without having to wait for RCTs to be retracted by journals or expressions of concern issued. This article analyzes the issues and challenges in conducting evidence syntheses where the literature contains RCTs with possible integrity deficits. The way forward in the form of formal RCT integrity assessments in systematic reviews is proposed, and implications of this new initiative are discussed. Future directions include emphasizing ethical and professional standards, providing tailored integrity-specific training, and creating systems to promote research integrity, as improvements in RCT integrity will benefit evidence syntheses.

A comprehensive systematic review of colorectal cancer screening clinical practices guidelines and consensus statements

High-quality clinical practice guidelines (CPGs) and consensus statements (CSs) are essential for evidence-based medicine. The purpose of this systematic review was to appraise the quality and reporting of colorectal cancer (CRC) screening CPGs and CSs. After prospective registration (Prospero no: CRD42021286156), a systematic review searched CRC guidances in duplicate without language restrictions in ten databases, 20 society websites, and grey literature from 2018 to 2021. We appraised quality with AGREE II (% of maximum score) and reporting with RIGHT (% of total 35 items) tools. Twenty-four CPGs and 5 CSs were analysed. The median overall quality and reporting were 54.0% (IQR 45.7-75.0) and 42.0% (IQR 31.4-68.6). The applicability had low quality (AGREE II score <50%) in 83% of guidances (24/29). Recommendations and conflict of interest were low-reported (RIGHT score <50%) in 62% guidances (18/29) and 69% (20/29). CPGs that deployed systematic reviews had better quality and reporting than CSs (AGREE: 68.5% vs. 35.5%; p = 0.001; RIGHT: 74.6% vs. 41.4%; p  =  0.001). In summary, CRC screening CPGs and CSs achieved low quality and reporting. It is necessary a revision and an improvement of the current guidances. Their development should apply a robust methodology using proper guideline development tools to obtain high-quality evidence-based documents.

Dietary intake of polychlorinated dibenzo-p-dioxins and furans, adiposity and obesity status

INTRODUCTION

The principal source of exposure to Polychlorinated dibenzo-p-dioxins and polychlorinated dibenzo-p-furans (PCDD/Fs) in humans comes from food intake. PCDD/Fs, are a family of potential endocrine disruptors and have been associated with different chronic diseases such as diabetes and hypertension. However, studies assessing the relationship between dietary exposure to PCDD/Fs and adiposity or obesity status in a middle-aged population are limited.

OBJECTIVE

To assess cross-sectionally and longitudinally the associations between estimated dietary intake (DI) of PCDD/Fs and body mass index (BMI), waist circumference, and the prevalence/incidence of obesity and abdominal obesity in a middle-aged population.

METHODS

In 5899 participants aged 55-75 years (48% women) living with overweight/obesity from the PREDIMED-plus cohort, PCDD/Fs DI was estimated using a 143-item validated food-frequency questionnaire, and the levels of food PCDD/F expressed as Toxic Equivalents (TEQ). Consequently, cross-sectional and prospective associations between baseline PCDD/Fs DI (in pgTEQ/week) and adiposity or obesity status were assessed at baseline and after 1-year follow-up using multivariable cox, logistic or linear regression models.

RESULTS

Compared to participants in the first PCDD/F DI tertile, those in the highest tertile presented a higher BMI (β-coefficient [confidence interval]) (0.43kg/m2 [0.22; 0.64]; P-trend <0.001), a higher waist circumference (1.11 cm [0.55; 1.66]; P-trend <0.001), and a higher prevalence of obesity and abdominal obesity (1.05 [1.01; 1.09] and 1.02 [1.00; 1.03]; P-trend = 0.09 and 0.027, respectively). In the prospective analysis, participants in the top PCDD/F DI baseline tertile showed an increase in waist circumference compared with those in the first tertile after 1-year of follow-up (β-coefficient 0.37 cm [0.06; 0.70]; P-trend = 0.015).

CONCLUSION

Higher DI of PCDD/Fs was positively associated with adiposity parameters and obesity status at baseline and with changes in waist circumference after 1-year of follow-up in subjects living with overweight/obesity. Further large prospective studies using a different population with longer follow-up periods are warranted in the future to strengthen our results.

Smartphone Apps for Domestic Violence Prevention: A Systematic Review

Smartphone applications or apps are increasingly being produced to help with protection against the risk of domestic violence. There is a need to formally evaluate their features.

OBJECTIVE

This study systematically reviewed app-based interventions for domestic violence prevention, which will be helpful for app developers.

METHODS

We overviewed all apps concerning domestic violence awareness and prevention without language restrictions, collating information about features and limitations. We conducted searches in Google, the Google Play Store, and the App Store (iOS) covering a 10-year time period (2012-2022). We collected data related to the apps from the developers' descriptions, peer reviewed research articles, critical reviews in blogs, news articles, and other online sources.

RESULTS

The search identified 621 potentially relevant apps of which 136 were selected for review. There were five app categories: emergency assistance (n = 61, 44.9%), avoidance (n = 29, 21.3%), informative (n = 29, 21.3%), legal information (n = 10, 7.4%), and self-assessment (n = 7, 5.1%). Over half the apps (n = 97, 71%) were released in 2020-22. Around a half were from north-east America (n = 63, 46.3%). Where emergency alerts existed, they required triggering by the potential victim. There was no automation. Content analysis showed 20 apps with unique features, including geo-fences, accelerometer-based alert, shake-based alert, functionality under low resources, alert auto-cancellation, anonymous communication, and data encryption. None of the apps deployed artificial intelligence to assist the potential victims.

CONCLUSIONS

Apps currently have many limitations. Future apps should focus on automation, making better use of artificial intelligence deploying multimedia (voice, video, image capture, text and sentiment analysis), speech recognition, and pitch detection to aid in live analysis of the situation and for accurately generating emergency alerts.

Video Consultations and Safety App Targeting Pregnant Women Exposed to Intimate Partner Violence in Denmark and Spain: Nested Cohort Intervention Study (STOP Study)

BACKGROUND

Intimate partner violence (IPV) during pregnancy is a public health issue with wide-ranging consequences for both the mother and fetus, and interventions are needed. Therefore, the Stop Intimate Partner Violence in Pregnancy (STOP) cohort was established with the overall aim to identify pregnant women exposed to IPV through digital screening and offer women screening positive for IPV a digital supportive intervention.

OBJECTIVE

The aim of this study was to (1) introduce the design and profile of the STOP cohort study, (2) assess the feasibility of implementing digital IPV screening among pregnant women, and (3) assess the feasibility of implementing a digital supportive intervention targeting pregnant women exposed to IPV.

METHODS

Pregnant women attending antenatal care in the Region of Southern Denmark and in Andalucía, Spain were offered digital screening for IPV using validated scales (Abuse Assessment Screen and Women Abuse Screening Tool). Women who screened positive were eligible to receive a digital supportive intervention. The intervention consisted of 3-6 video consultations with an IPV counselor and a safety planning app. In Denmark, IPV counselors were antenatal care midwives trained by a psychologist specialized in IPV, whereas in Spain, the counselor was a psychologist.

RESULTS

Data collection started in February 2021 and was completed in October 2022. Across Denmark and Spain, a total of 19,442 pregnant women were invited for IPV screening and 16,068 women (82.65%) completed the screening. More women in Spain screened positive for exposure to IPV (350/2055, 17.03%) than in Denmark (1195/14,013, 8.53%). Among the women who screened positive, only 31.39% (485/1545) were eligible to receive the intervention with only 104 (21.4%) of these women ultimately receiving it.

CONCLUSIONS

Digital screening for IPV among pregnant women is feasible in an antenatal care context in Denmark and Spain; however, a digital supportive intervention during pregnancy appears to have limited feasibility as only a minor subgroup of women who screened positive for eligibility received the intervention. More research is needed on how to best support pregnant women exposed to IPV if universal IPV screening is to be implemented in antenatal care.

Evidence-based medicine needs patient and public involvement to remain relevant: A proposal for a new curriculum

INTRODUCTION

Public partnerships, a route to sharing expertise, networks and resources anchored in the United Nations Sustainable Development Goals, has been championed by multiple stakeholders.

OBJECTIVE

To propose a new evidence-based medicine (EBM) curriculum for harnessing patient and public expertise to ensure that EBM teaching and learning can become more relevant and impactful.

METHODS

A curriculum development group comprising of EBM teachers, patient and public involvement representatives, clinicians, clinical epidemiologists, public health experts and educationalists, with experience of delivering and evaluating face-to-face and online EBM courses across many countries and continents, prepared a new EBM course.

RESULTS

A student-centred, problem-based and clinically integrated course for teaching and learning EBM was developed. In the spirit of shared decision-making, practitioners can learn to support patients, articulate their perspectives, recognise the need for their contribution and ensure community involvement when generating and applying evidence. With end users in mind, the application of research findings, delivery of care and EBM effectiveness in the workplace would carry increased priority.

CONCLUSIONS

Embracing patients as EBM collaborators can help deliver cognitive diversity and inspire different ways of thinking and working. Adopting the proposed approach in EBM education lays the foundations for a joint practitioner-patient partnership to ask, acquire, appraise and apply EBM in a more holistic context which will strengthen the EBM proposition.

Impact of COVID-19 pandemic on the PREDIMED-Plus randomized clinical trial: Effects on the interventions, participants follow-up, and adiposity

Background

The COVID-19 pandemic has affected the implementation of most ongoing clinical trials worldwide including the PREDIMED-Plus study. The PREDIMED-Plus is an ongoing, multicenter, controlled intervention trial, aimed at weight-loss and cardiovascular disease prevention, in which participants were randomized (1:1 ratio) to an intervention group (energy-reduced Mediterranean diet, promotion of physical activity, and behavioral support) or to a control group (Mediterranean diet with usual care advice). When the pandemic began, the trial was in the midst of the planned intervention. The objective of this report was to examine the effects of the pandemic on the delivery of the intervention and to describe the strategies established to mitigate the possible adverse effects of the pandemic lockdown on data collection and adiposity.

Methods

We assessed the integrity of the PREDIMED-Plus trial during 5 identified periods of the COVID-19 pandemic determined according to restrictions dictated by the Spanish government authorities. A standardized questionnaire was delivered to each of the 23 PREDIMED-Plus recruiting centers to collected data regarding the trial integrity. The effect of the restrictions on intervention components (diet, physical activity) was evaluated with data obtained in the three identified lockdown phases: pre lockdown, lockdown proper, and post lockdown.

Results

During the lockdown (March/2020-June/2021), 4,612 participants (48% women, mean age 65y) attended pre-specified yearly follow-up visits to receive lifestyle recommendations and obtain adiposity measures. The overall mean (SD) of the proportions reported by each center showed that 40.4% (25.4) participants had in-person visits, 39.8% (18.2) participants were contacted by telephone and 35% (26.3) by electronic means. Participants' follow-up and data collection rates increased across lockdown periods (from ≈10% at onset to ≈80% at the end). Compared to pre-lockdown, waist circumference increased during (0.75 cm [95% CI: 0.60-0.91]) and after (0.72 cm [95% CI: 0.56-0.89]) lockdown. Body weight did not change during lockdown (0.01 kg [95% CI: -0.10 to 0.13) and decreased after lockdown (-0.17 kg [95% CI: -0.30 to -0.04]).

Conclusion

Mitigating strategies to enforce the intervention and patient's follow-up during lockdown have been successful in preserving the integrity of the trial and ensuring its continuation, with minor effects on adiposity.

Clinical trial registration

https://doi.org/10.1186/ISRCTN89898870, identifier ISRCTN89898870.

Decision Aids for Decision Making about Locally Advance Breast Cancer: A Systematic Review

Locally advanced breast cancer (LABC) is a subset of breast cancer with locoregional progression without distant metastasis. The multimodality treatment (surgery, chemotherapy, radiotherapy, hormonal and targeted therapy if required) could significantly improve results in this specific group of patients. The complex and multiple options of treatment with similar mortality rates but different outcomes depending on the patient's desires, preferences and social environment require aid to facilitate the individual patient's decisions (e.g. Decision Aids (DAs) targeting patients considering primary or adjuvant treatment in LABC). In this context, DAs have been proven fundamental to help patients and clinicians share and agree on the best value option. The current systematic review aimed to evaluate the existing DAs related to these patients with LABC and identify current status and possible improvement areas (possible scarcity and heterogeneity of instruments, the status of their development, explanation of their purpose,…). No previous systematic reviews have been published on this topic. Following Prospero registration no: CRD42021286173, studies about LABC DAs were identified, without data or language restrictions, through a systematic search of bibliographic databases in December 2021. Quality was assessed using Qualsyst criteria (range 0.0-1.0). The quality of the 17 selected studies ranged from 0.46 to 0.95. Of them, 14/17 (82%) were DAs about treatment, only one (6%) about diagnosis, and 2/17 (12%) about the employment of DAs. No screening or follow-up DAs were retrieved. Twelve (70.6%) DAs were online tools. They varied broadly regarding their characteristics and purposes. Most of the studies focused on developing and testing different DAs (5/17; 29.4%) and their impact (7/17; 41.2%). Only 4/17 (23.5%) analysed their implementation and cost. These instruments have proven to improve patient's knowledge and decision-making, decrease patient anxiety, and patients tend to undergo treatment. However, nowadays, there is still a need for further research and consensus on methodology to develop practical DAs.

Intensive Weight-Loss Lifestyle Intervention Using Mediterranean Diet and COVID-19 Risk in Older Adults: Secondary Analysis of PREDIMED-Plus Trial

OBJECTIVES

We tested the effects of a weight-loss intervention encouraging energy-reduced MedDiet and physical activity (PA) in comparison to ad libitum MedDiet on COVID-19 incidence in older adults.

DESIGN

Secondary analysis of PREDIMED-Plus, a prospective, ongoing, multicentre randomized controlled trial.

SETTING

Community-dwelling, free-living participants in PREDIMED-Plus trial.

PARTICIPANTS

6,874 Spanish older adults (55-75 years, 49% women) with overweight/obesity and metabolic syndrome.

INTERVENTION

Participants were randomised to Intervention (IG) or Control (CG) Group. IG received intensive behavioural intervention for weight loss with an energy-reduced MedDiet intervention and PA promotion. CG was encouraged to consume ad libitum MedDiet without PA recommendations.

MEASUREMENTS

COVID-19 was ascertained by an independent Event Committee until December 31, 2021. COX regression models compared the effect of PREDIMED-Plus interventions on COVID-19 risk.

RESULTS

Overall, 653 COVID-19 incident cases were documented (IG:317; CG:336) over a median (IQR) follow-up of 5.8 (1.3) years (inclusive of 4.0 (1.2) years before community transmission of COVID-19) in both groups. A significantly lowered risk of COVID-19 incidence was not evident in IG, compared to CG (fully-adjusted HR (95% CI): 0.96 (0.81,1.12)).

CONCLUSIONS

There was no evidence to show that an intensive weight-loss intervention encouraging energy-reduced MedDiet and PA significantly lowered COVID-19 risk in older adults with overweight/obesity and metabolic syndrome in comparison to ad libitum MedDiet. Recommendations to improve adherence to MedDiet provided with or without lifestyle modification suggestions for weight loss may have similar effects in protecting against COVID-19 risk in older adults with high cardiovascular risks.

Variations in Author Gender in Obstetrics Disease Prevalence Literature: A Systematic Review

This systematic review aims to evaluate gender differences in authorship of prevalence literature concerning intimate partner violence (IPV) during pregnancy and gestational diabetes mellitus (GDM). GDM studies were matched for publication year and study country as a gender-neutral obstetric disease with similar morbidity to IPV. Relevant studies were captured without language restrictions via online searches of PubMed, Scopus and Web of Science from database inception to January 2022. Proportion of female authors and gender of the first and corresponding author were outcome measures. Multivariable regression models were built to examine if female authors featured more or less often in IPV during pregnancy and GDM literature adjusting by the influence of type of study, country's human development index (HDI), year of publication and journal's impact factor. 137 IPV-GDM studies pairs were included. Female authors in IPV studies were slightly lower than in GDM [59.7%, 95% CI 54.7-64.7, vs. 54.9%, 95% CI 50.7-59.1, p = 0.204]. Studies published in high-income countries were more likely to be signed by a woman as first and corresponding author (Odds Ratio 2.22, 95% CI 1.20; 4.11, p = 0.011 and Odds Ratio 2.24, CI 1.22; 4.10, p = 0.009 respectively) and proportion of women as corresponding authors decreased as the journal impact factor increased (β = 0.62, 95% CI 0.37, 1.05, p = 0.075). There is a gender gap in the field of prevalence research in IPV during pregnancy with variations according to the level of development. International programs aimed at eradicating these inequalities are needed.

One-year longitudinal association between changes in dietary choline or betaine intake and cardiometabolic variables in the PREvención con DIeta MEDiterránea-Plus (PREDIMED-Plus) trial

BACKGROUND

Choline and betaine intakes have been related to cardiovascular health.

OBJECTIVES

We aimed to explore the relation between 1-y changes in dietary intake of choline or betaine and 1-y changes in cardiometabolic and renal function traits within the frame of the PREDIMED (PREvención con DIeta MEDiterránea)-Plus trial.

METHODS

We used baseline and 1-y follow-up data from 5613 participants (48.2% female and 51.8% male; mean ± SD age: 65.01 ± 4.91 y) to assess cardiometabolic traits, and 3367 participants to assess renal function, of the Spanish PREDIMED-Plus trial. Participants met ≥3 criteria of metabolic syndrome and had overweight or obesity [BMI (in kg/m2) ≥27 and ≤40]. These criteria were similar to those of the PREDIMED parent study. Dietary intakes of choline and betaine were estimated from the FFQ.

RESULTS

The greatest 1-y increase in dietary choline or betaine intake (quartile 4) was associated with improved serum glucose concentrations (-3.39 and -2.72 mg/dL for choline and betaine, respectively) and HbA1c levels (-0.10% for quartile 4 of either choline or betaine intake increase). Other significant changes associated with the greatest increase in choline or betaine intake were reduced body weight (-2.93 and -2.78 kg, respectively), BMI (-1.05 and -0.99, respectively), waist circumference (-3.37 and -3.26 cm, respectively), total cholesterol (-4.74 and -4.52 mg/dL, respectively), and LDL cholesterol (-4.30 and -4.16 mg/dL, respectively). Urine creatinine was reduced in quartile 4 of 1-y increase in choline or betaine intake (-5.42 and -5.74 mg/dL, respectively).

CONCLUSIONS

Increases in dietary choline or betaine intakes were longitudinally related to improvements in cardiometabolic parameters. Markers of renal function were also slightly improved, and they require further investigation.This trial was registered at https://www.isrctn.com/ as ISRCTN89898870.

Caffeine Intake throughout Pregnancy, and Factors Associated with Non-Compliance with Recommendations: A Cohort Study

Maternal caffeine consumption is associated with adverse gestational outcomes. The aim of this study was to assess the intake of caffeine and factors associated with the non-adherence to caffeine intake recommendations in a cohort of 463 women before (T0) and in each trimester of gestation (T1, T2, and T3), by using validated questionnaires. Caffeine intake (median (mg/day), IQR) was 100.0 (181.1) at T0, 9.42 (66.2) at T1, 12.5 (65.6) at T2, and 14.0 (61.1) at T3 (p < 0.001). Non-compliance prevalence (intake > 200 mg/day) was 6.2% at T1, 4.2% at T2, and 2.7% at T3. Not being an active smoker at T1 (OR = 0.17; 95% CI 0.05−0.59) and T2 (OR = 0.22; 95% CI 0.09−0.52), adherence to the Mediterranean Diet at T1 (OR = 0.50; 95% CI 0.28−0.88) and T2 (OR = 0.39; 95% CI 0.15−1.02), and moderate physical activity at T1 (OR = 0.50; 95% CI 0.28−0.88) were inversely associated with caffeine consumption. Although caffeine intake may be considered low, intake prevalence increases throughout pregnancy. Although the main source of caffeine during pregnancy is coffee, attention must be also paid to the increasingly intake of chocolate, of which the effect during pregnancy is controversial. Smoking, non-adherence to a good quality diet, and light physical activity are associated with a higher caffeine intake and a lower compliance with caffeine intake recommendations. Perinatal dietary and lifestyle educational policies are needed.

Second Victim Support at the Core of Severe Adverse Event Investigation

There is limited evidence and a lack of standard operating procedures to address the impact of serious adverse events (SAE) on healthcare workers. We aimed to share two years' experience of a second victim support intervention integrated into the SAE management program conducted in a 500-bed University Hospital in Granada, Spain. The intervention strategy, based on the "forYOU" model, was structured into three levels of support according to the degree of affliction and the emotional needs of the professionals. A semi-structured survey of all workers involved in an SAE was used to identify potential second victims. Between 2020 and 2021, the SAE operating procedure was activated 23 times. All healthcare workers involved in an SAE (n = 135) received second-level support. The majority were physicians (51.2%), followed by nurses (26.7%). Only 58 (43.0%) received first-level emotional support and 47 (34.8%) met "second victim" criteria. Seven workers (14.9%) required third-level support. A progressive increase in the notification rates was observed. Acceptance of the procedure by professionals and managers was high. This novel approach improved the number of workers reached by the trained staff; promoted the visibility of actions taken during SAE management and helped foster patient safety culture in our setting.

Guidance documents for colorectal and anal cancer treatment: A systematic quality and reporting assessment

AIM

Evidence-based medicine is essential for clinical practice. Clinical practice guidelines (CPGs) and consensus statements (CSs) ought to follow a consistent methodology to underpin high-quality healthcare. We systematically analysed the quality and reporting of colorectal (CRC) and anal cancer CPGs and CSs.

METHODS

Embase, MEDLINE, Scopus, Web of Science, the Cochrane Database of Systematic Reviews and online sources (59 professional society websites and eight guideline databases) were systematically searched following prospective registration (PROSPERO no. CRD42021286146) by two reviewers independently, without language restrictions. CPGs and CSs about CRC and anal cancer treatment were included from January 2018 to November 2021 and were assessed using the AGREE II tool (per cent of maximum score) and the RIGHT tool (per cent of total 35 items) for quality and reporting respectively.

RESULTS

The median overall quality and reporting of the 59 guidelines analysed were 55.0% (interquartile range 47.0-62.0) and 58% (interquartile range 50.0-67.9), respectively, with a proportion scoring less than half (<50%) for quality (20/59, 33.9%) and reporting (15/59, 25.4%). Guidance reported that following AGREE II methodology scored better on average than that without (AGREE II 77.7% vs. 47.6%, P = 0.001; RIGHT 50.0% vs. 33.9%, P = 0.001). Guidelines based on systematic reviews had better quality and reporting on average than those based on consensus (AGREE II 56.5% vs. 46.6%, P = 0.001; RIGHT 36.9% vs. 35.4%, P = 0.019).

CONCLUSION

The quality and reporting of colorectal and anal cancer treatment CPGs and CSs were poor. Despite AGREE II and RIGHT inherent methodological limitations, few high-quality guidelines were found. Despite wide variability in scoring different domains, they merit urgent improvement in all areas. It has also been demonstrated that CPGs and CSs should be underpinned by systematic reviews collecting the best available clinical research findings.

Benefits of Participation in Clinical Trials: An Umbrella Review

Participation in randomised clinical trials (RCTs) entails taking part in the discovery of effects of health care interventions. The question of whether participants' outcomes are different to those of non-participants remains controversial. This umbrella review was aimed at assessing whether there are health benefits of participation in RCTs, compared to non-participation. After prospective registration (PROSPERO CRD42021287812), we searched the Medline, Scopus, Web of Science and Cochrane Library databases from inception to June 2022 to identify relevant systematic reviews with or without meta-analyses. Data extraction and study quality assessment (AMSTAR-2) were performed by two independent reviewers. Of 914 records, six systematic reviews summarising 380 comparisons of RCT participants with non-participants met the inclusion criteria. In two reviews, the majority of comparisons were in favour of participation in RCTs. Of the total of comparisons, 69 (18.7%) were in favour of participation, reporting statistically significant better outcomes for patients treated within RCTs, 264 (71.7%) comparisons were not statistically significant, and 35 (9.5%) comparisons were in favour of non-participation. None of the reviews found a harmful effect of participation in RCTs. Our findings suggest that taking part in RCTs may be beneficial compared to non-participation.

Does Consumption of Ultra-Processed Foods Matter for Liver Health? Prospective Analysis among Older Adults with Metabolic Syndrome

Non-alcoholic fatty liver disease (NAFLD) includes a spectrum of liver alterations that can result in severe disease and even death. Consumption of ultra-processed foods (UPF) has been associated with obesity and related comorbidities. However, the link between UPF and NAFLD has not been sufficiently assessed. We aimed to investigate the prospective association between UPF consumption and liver health biomarkers. Methods: We followed for 1 year 5867 older participants with overweight/obesity and metabolic syndrome (MetS) from the PREDIMED-Plus trial. A validated 143-item semi-quantitative food frequency questionnaire was used to evaluate consumption of UPF at baseline, 6, and 12 months. The degree of processing for foods and beverages (g/day) was established according to the NOVA classification system. The non-invasive fatty liver index (FLI) and hepatic steatosis index (HSI) were used to evaluate liver health at three points in time. The associations between changes in UPF consumption (percentage of total daily dietary intake (g)) and liver biomarkers were assessed using mixed-effects linear models with repeated measurements. Results: In this cohort, UPF consumption at baseline was 8.19% (SD 6.95%) of total daily dietary intake in grams. In multivariable models, each 10% daily increment in UPF consumption in 1 year was associated with significantly greater FLI (β 1.60 points, 95% CI 1.24;1.96 points) and HSI (0.43, 0.29; 0.57) scores (all p-values < 0.001). These associations persisted statistically significant after adjusting for potential dietary confounders and NAFLD risk factors. Conclusions: A higher UPF consumption was associated with higher levels of NAFLD-related biomarkers in older adults with overweight/obesity and MetS.

Research integrity in clinical trials: innocent errors and spin versus scientific misconduct

PURPOSE OF REVIEW

High-quality research underpins the best healthcare practice. This article focuses on analyzing the current literature to promote research integrity across clinical trials.

RECENT FINDINGS

Recent admissions of questionable practices by researchers have undermined practitioner and public confidence. There is limited evidence specifically for ethical and professional standards in clinical trials to guide researchers and institutions to embed integrity into research practice.

SUMMARY

Unintentional errors and spin in research are not uncommon as training in design and conduct of clinical trials is not part of health education for medical and allied health professions. There is unfamiliarity with procedures, such as prospective registration, a priori documentation of statistical analysis plans, openness in data sharing, and so forth. This, combined with the academic culture of secrecy, has led to an environment where scientific suspicion, instead of trust, is the norm. Existing science integrity documents are devoid of specific recommendations about how to translate any guidance into clinical trial practice. There is a need for constructive, supportive and multidisciplinary approaches based on open dialogue and continuous training, targeting the research environment. Research integrity now needs to take centre stage to re-instill confidence in randomized trial evidence to inform clinical practice.

Longitudinal association of dietary acid load with kidney function decline in an older adult population with metabolic syndrome

Background

Diets high in acid load may contribute to kidney function impairment. This study aimed to investigate the association between dietary acid load and 1-year changes in glomerular filtration rate (eGFR) and urine albumin/creatinine ratio (UACR).

Methods

Older adults with overweight/obesity and metabolic syndrome (mean age 65 ± 5 years, 48% women) from the PREDIMED-Plus study who had available data on eGFR (n = 5,874) or UACR (n = 3,639) at baseline and after 1 year of follow-up were included in this prospective analysis. Dietary acid load was estimated as potential renal acid load (PRAL) and net endogenous acid production (NEAP) at baseline from a food frequency questionnaire. Linear and logistic regression models were fitted to evaluate the associations between baseline tertiles of dietary acid load and kidney function outcomes. One year-changes in eGFR and UACR were set as the primary outcomes. We secondarily assessed ≥ 10% eGFR decline or ≥10% UACR increase.

Results

After multiple adjustments, individuals in the highest tertile of PRAL or NEAP showed higher one-year changes in eGFR (PRAL, β: -0.64 ml/min/1.73 m2; 95% CI: -1.21 to -0.08 and NEAP, β: -0.56 ml/min/1.73 m2; 95% CI: -1.13 to 0.01) compared to those in the lowest category. No associations with changes in UACR were found. Participants with higher levels of PRAL and NEAP had significantly higher odds of developing ≥10% eGFR decline (PRAL, OR: 1.28; 95% CI: 1.07-1.54 and NEAP, OR: 1.24; 95% CI: 1.03-1.50) and ≥10 % UACR increase (PRAL, OR: 1.23; 95% CI: 1.04-1.46) compared to individuals with lower dietary acid load.

Conclusions

Higher PRAL and NEAP were associated with worse kidney function after 1 year of follow-up as measured by eGFR and UACR markers in an older Spanish population with overweight/obesity and metabolic syndrome.

Circulating carotenoids are associated with favorable lipid and fatty acid profiles in an older population at high cardiovascular risk

Carotenoid intake has been reported to be associated with improved cardiovascular health, but there is little information on actual plasma concentrations of these compounds as biomarkers of cardiometabolic risk. The objective was to investigate the association between circulating plasma carotenoids and different cardiometabolic risk factors and the plasma fatty acid profile. This is a cross-sectional evaluation of baseline data conducted in a subcohort (106 women and 124 men) of an ongoing multi-factorial lifestyle trial for primary cardiovascular prevention. Plasma concentrations of carotenoids were quantified by liquid chromatography coupled to mass spectrometry. The associations between carotenoid concentrations and cardiometabolic risk factors were assessed using regression models adapted for interval-censored variables. Carotenoid concentrations were cross-sectionally inversely associated with serum triglyceride concentrations [−2.79 mg/dl (95% CI: −4.25, −1.34) and −5.15 mg/dl (95% CI: −7.38, −2.93), p-values = 0.0002 and <0.00001 in women and men, respectively], lower levels of plasma saturated fatty acids [−0.09% (95% CI: −0.14, −0.03) and −0.15 % (95% CI: −0.23, −0.08), p-values = 0.001 and 0.0001 in women and men, respectively], and higher levels of plasma polyunsaturated fatty acids [(0.12 % (95% CI: −0.01, 0.25) and 0.39 % (95% CI: 0.19, 0.59), p-values = 0.065 and 0.0001 in women and men, respectively] in the whole population. Plasma carotenoid concentrations were also associated with higher plasma HDL-cholesterol in women [0.47 mg/dl (95% CI: 0.23, 0.72), p-value: 0.0002], and lower fasting plasma glucose in men [−1.35 mg/dl (95% CI: −2.12, −0.59), p-value: 0.001].

Artificial intelligence in COVID-19 evidence syntheses was underutilized, but impactful: a methodological study

OBJECTIVES

A rapidly developing scenario like a pandemic requires the prompt production of high-quality systematic reviews, which can be automated using artificial intelligence (AI) techniques. We evaluated the application of AI tools in COVID-19 evidence syntheses.

STUDY DESIGN

After prospective registration of the review protocol, we automated the download of all open-access COVID-19 systematic reviews in the COVID-19 Living Overview of Evidence database, indexed them for AI-related keywords, and located those that used AI tools. We compared their journals' JCR Impact Factor, citations per month, screening workloads, completion times (from pre-registration to preprint or submission to a journal) and AMSTAR-2 methodology assessments (maximum score 13 points) with a set of publication date matched control reviews without AI.

RESULTS

Of the 3,999 COVID-19 reviews, 28 (0.7%, 95% CI 0.47-1.03%) made use of AI. On average, compared to controls (n = 64), AI reviews were published in journals with higher Impact Factors (median 8.9 vs. 3.5, P < 0.001), and screened more abstracts per author (302.2 vs. 140.3, P = 0.009) and per included study (189.0 vs. 365.8, P < 0.001) while inspecting less full texts per author (5.3 vs. 14.0, P = 0.005). No differences were found in citation counts (0.5 vs. 0.6, P = 0.600), inspected full texts per included study (3.8 vs. 3.4, P = 0.481), completion times (74.0 vs. 123.0, P = 0.205) or AMSTAR-2 (7.5 vs. 6.3, P = 0.119).

CONCLUSION

AI was an underutilized tool in COVID-19 systematic reviews. Its usage, compared to reviews without AI, was associated with more efficient screening of literature and higher publication impact. There is scope for the application of AI in automating systematic reviews.

Undercarboxylated Osteocalcin: A Promising Target for Early Diagnosis of Cardiovascular and Glycemic Disorders in Patients with Metabolic Syndrome: A Pilot Study

Lifestyle changes are causing an exponential increase in the prevalence of obesity and metabolic syndrome (MetS) worldwide. The most frequent complications of these are the development of diabetes (T2D) and cardiovascular disease (CVD). Accurate tools are needed to classify the cardiovascular risk (CVR) in the MetS population. In recent years, numerous biomarkers of bone metabolism have been associated with CVR. The aim of this study was to determine the levels of undercarboxylated osteocalcin (ucOC) in a cohort of patients with MetS and to analyse its association with MetS parameters and CVR as well as with T2D prevalence. A longitudinal study was conducted in which a MetS population was followed for one year. Weight change, adherence to the Mediterranean diet (MedDiet), ucOC levels, MetS parameters and CVR were analysed and CVR was calculated using different scores. Our results showed a decrease of CVR associated with a better adherence to the MetDiet resulting in higher HDL-C and ucOC levels though the improvement of MetS risk factors. This bone protein appeared as a potential biomarker to classify CVR in the MetS population, especially for MetS patients without prevalent T2D. Furthermore, ucOC serum levels could be good predictors of T2D prevalence.

Dietary diversity and depression: cross-sectional and longitudinal analyses in Spanish adult population with metabolic syndrome. Findings from PREDIMED-Plus trial

OBJECTIVE

To examine the cross-sectional and longitudinal (2-year follow-up) associations between dietary diversity (DD) and depressive symptoms.

DESIGN

An energy-adjusted dietary diversity score (DDS) was assessed using a validated FFQ and was categorised into quartiles (Q). The variety in each food group was classified into four categories of diversity (C). Depressive symptoms were assessed with Beck Depression Inventory-II (Beck II) questionnaire and depression cases defined as physician-diagnosed or Beck II >= 18. Linear and logistic regression models were used.

SETTING

Spanish older adults with metabolic syndrome (MetS).

PARTICIPANTS

A total of 6625 adults aged 55-75 years from the PREDIMED-Plus study with overweight or obesity and MetS.

RESULTS

Total DDS was inversely and statistically significantly associated with depression in the cross-sectional analysis conducted; OR Q4 v. Q1 = 0·76 (95 % CI (0·64, 0·90)). This was driven by high diversity compared to low diversity (C3 v. C1) of vegetables (OR = 0·75, 95 % CI (0·57, 0·93)), cereals (OR = 0·72 (95 % CI (0·56, 0·94)) and proteins (OR = 0·27, 95 % CI (0·11, 0·62)). In the longitudinal analysis, there was no significant association between the baseline DDS and changes in depressive symptoms after 2 years of follow-up, except for DD in vegetables C4 v. C1 = (β = 0·70, 95 % CI (0·05, 1·35)).

CONCLUSIONS

According to our results, DD is inversely associated with depressive symptoms, but eating more diverse does not seem to reduce the risk of future depression. Additional longitudinal studies (with longer follow-up) are needed to confirm these findings.

How Does Vaccination against SARS-CoV-2 Affect Hospitalized Patients with COVID-19?

(1) Background: The development of effective COVID-19 vaccines has reduced the impact of COVID-19 on the general population. Our study aims to analyze how vaccination modifies the likelihood of death and length of stay in hospitalized patients with COVID-19; (2) Methods: A retrospective cohort study of 1927 hospitalized patients infected with COVID-19 was conducted. Information was gathered on vaccination status, hospitalization episode, and clinical profile of the patients. The effect of vaccination on mortality was analyzed using a multiple logistic regression model, and length of stay was analyzed using linear regression. The performance and fit of the models were evaluated; (3) Results: In hospitalized patients with COVID-19, the risk of dying during admission in vaccinated patients was half that of non-vaccinated (OR: 0.45; CI 95%: 0.25 to 0.84). In patients who were discharged due to improvement, the reduction in hospital stay in vaccinated patients was 3.17 days (CI 95%: 5.88 to 0.47); (4) Conclusions: Patients who, despite having been vaccinated, acquire the infection by SARS-CoV-2, have a significant reduction of the risk of death during admission and a reduction of hospital stay compared with unvaccinated patients.

Influence of placebo effect in mental disorders research: A systematic review and meta-analysis

BACKGROUND

Randomized controlled trials (RCT) in mental disorders research commonly use active control groups including psychotherapeutic shams or inactive medication. This meta-analysis assessed whether placebo conditions (active controls) had an effect compared to no treatment or usual care (passive controls).

METHODS

PubMed, Scopus, PsycINFO, PsycARTICLES, Ovid, the Cochrane Central Register of Controlled Trials and Web of Science were searched from inception to April 2021 and reference lists of relevant articles. Three-arm RCTs, including active and passive control groups, were selected. Where individual standardized mean difference (SMD) was calculable, random effects meta-analyses were performed to estimate an overall effect size with 95% confidence intervals (CI) comparing active vs passive controls. Heterogeneity was assessed using I² statistic and meta-regression. Funnel asymmetry was evaluated using Egger's test (Prospero registration: CRD42021242940).

RESULTS

24 articles with 25 relevant RCTs were included in the review, of which 11 studies were of high risk of bias. There was an improvement in outcomes favouring the placebo conditions, compared to passive controls, overall (25 studies, SMD 0.24, 95% CI 0.06-0.42, I² = 43%) and in subgroups with anxiety (SMD 0.45, 95% CI 0.07-0.84, I² = 59%) or depression (SMD 0.22, 95% CI 0.04-0.39, I² = 0%). Meta-regression did not show a significant explanation for heterogeneity. Egger's test showed no asymmetry (p = .200).

CONCLUSIONS

A small placebo effect was observed in mental disorders research overall, and in patients with anxiety or depression. These findings should be interpreted with caution in the light of heterogeneity and risk of bias.

Dairy Product Consumption and Changes in Cognitive Performance: Two-Year Analysis of the PREDIMED-Plus Cohort

SCOPE

Dairy consumption has been suggested to impact cognition; however, evidence is limited and inconsistent. This study aims to longitudinally assess the association between dairy consumption with cognitive changes in an older Spanish population at high cardiovascular disease risk.

METHODS AND RESULTS

Four thousand six hundred sixty eight participants aged 55-75 years, completed a validated food frequency questionnaire at baseline and a neuropsychological battery of tests at baseline and 2-year follow-up. Multivariable linear regression models are used, scaled by 100 (i.e., the units of β correspond to 1 SD/100), to assess associations between baseline tertile daily consumption and 2-year changes in cognitive performance. Participants in the highest tertile of total milk and whole-fat milk consumption have a greater decline in global cognitive function (β: -4.71, 95% CI: -8.74 to -0.69, p-trend = 0.020 and β: -6.64, 95% CI: -10.81 to -2.47, p-trend = 0.002, respectively) compared to those in the lowest tertile. No associations are observed between low fat milk, yogurt, cheese or fermented dairy consumption, and changes in cognitive performance.

CONCLUSION

Results suggest there are no clear prospective associations between consumption of most commonly consumed dairy products and cognition, although there may be an association with a greater rate of cognitive decline over a 2-year period in older adults at high cardiovascular disease risk for whole-fat milk.

Contribution of cardio-vascular risk factors to depressive status in the PREDIMED-PLUS Trial. A cross-sectional and a 2-year longitudinal study

BACKGROUND

Cardio-vascular disease and depression are thought to be closely related, due to shared risk factors. The aim of the study was to determine the association between cardio-vascular risk (CVR) factors and depressive status in a population (55-75 years) with metabolic syndrome (MetS) from the PREDIMED-Plus trial.

METHODS AND FINDINGS

Participants were classified into three groups of CVR according to the Framingham-based REGICOR function: (1) low (LR), (2) medium (MR) or (3) high/very high (HR). The Beck Depression Inventory-II (BDI-II) was used to assess depressive symptoms at baseline and after 2 years. The association between CVR and depressive status at baseline (n = 6545), and their changes after 2 years (n = 4566) were evaluated through multivariable regression models (logistic and linear models). HR women showed higher odds of depressive status than LR [OR (95% CI) = 1.78 (1.26, 2.50)]. MR and HR participants with total cholesterol <160 mg/mL showed higher odds of depression than LR [OR (95% CI) = 1.77 (1.13, 2.77) and 2.83 (1.25, 6.42) respectively)] but those with total cholesterol ≥280 mg/mL showed lower odds of depression than LR [OR (95% CI) = 0.26 (0.07, 0.98) and 0.23 (0.05, 0.95), respectively]. All participants decreased their BDI-II score after 2 years, being the decrease smaller in MR and HR diabetic compared to LR [adjusted mean±SE = -0.52±0.20, -0.41±0.27 and -1.25±0.31 respectively). MR and HR participants with total cholesterol between 240-279 mg/mL showed greater decreases in the BDI-II score compared to LR (adjusted mean±SE = -0.83±0.37, -0.77±0.64 and 0.97±0.52 respectively).

CONCLUSIONS

Improving cardiovascular health could prevent the onset of depression in the elderly. Diabetes and total cholesterol in individuals at high CVR, may play a specific role in the precise response. International Standard Randomized Controlled Trial (ISRCTN89898870).

Association between Dietary Diversity and All-Cause Mortality: A Multivariable Model in a Mediterranean Population with 18 Years of Follow-Up

We evaluated the relationship between the dietary diversity score (DDS) and all-cause, CVD and cancer mortality in an adult Mediterranean population. We analyzed the data of 1540 participants from the Valencia Nutrition Survey. The DDS was estimated using a validated food frequency questionnaire and was categorized into quartiles (Q), where the first quartile indicates the lowest dietary diversity. Deaths were ascertained during an 18-year follow-up period. Cox regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI). There were 403 deaths during the follow-up period (40% due to CVD). An inverse association was observed between the DDS and all-cause and CVD mortality. Compared with participants in the lowest DDS quartile (Q1), participants in the highest DDS quartile (Q4) showed 32% and 45% less risk of death for all-cause and CVD mortality, in sex- and age-adjusted models, respectively. Regarding the food groups in the DDS, an inverse association was identified between total vegetable consumption diversity and all-cause and CVD mortality in the highest quartiles, (Q3 vs. Q1, HR: 0.70; 95% CI: 0.50, 0.99) and (Q4 vs. Q1, HR: 0.52; 95% CI: 0.30, 0.91), respectively. This study suggests that a higher diversity in food intake, particularly in vegetables, may be associated with a lower risk of all-cause and CVD mortality. This association should be further investigated in other wider populations.

Vitamin K dietary intake is associated with cognitive function in an older adult Mediterranean population

BACKGROUND

In the last years, evidence that dietary vitamin K could have a role in the cognitive domain has increased. However, data from large trials are limited. The objective of this study was to assess the association of 2 year changes in the dietary intake of vitamin K with cognitive function measured through neuropsychological performance tests.

METHODS

In 5,533 participants of the multicentre PREDIMED-Plus study (48.1% women, age 65.1 ± 4.9 years with overweight/obesity and metabolic syndrome), we assessed the adjusted odds ratios of cognitive function decline according to 2 year changes in vitamin K intake. Participants answered a battery of cognitive function tests and Food Frequency Questionnaires (FFQs) in order to estimate the vitamin K dietary intake.

RESULTS

After adjusting for potential cofounders, the highest tertile of change of dietary vitamin K intake (median [IQR]; 194.4 μg/d [120.9, 373.1]) was inversely associated with a Mini-Mental State Examination (MMSE) score ≤24 (OR [95% CI]; 0.53 [0.35, 0.79] P for trend = 0.002) compared with a decrease in the intake of vitamin K (median [IQR]; -97.8 μg/d [-292.8, -51.5]). A significant positive association between changes in dietary vitamin K intake and the semantic verbal fluency test scores (OR [95% CI]; 0.69 [0.51, 0.94] P for trend = 0.019) was found.

CONCLUSIONS

An increase of the intake of dietary vitamin K was associated with better cognitive function scores, independently of recognised risk factors for cognitive decline, in an older adult Mediterranean population with high cardiovascular risk.

Integrative development of a short screening questionnaire of highly processed food consumption (sQ-HPF)

BACKGROUND

Recent lifestyle changes include increased consumption of highly processed foods (HPF), which has been associated with an increased risk of non-communicable diseases (NCDs). However, nutritional information relies on the estimation of HPF consumption from food-frequency questionnaires (FFQ) that are not explicitly developed for this purpose. We aimed to develop a short screening questionnaire of HPF consumption (sQ-HPF) that integrates criteria from the existing food classification systems.

METHODS

Data from 4400 participants (48.1% female and 51.9% male, 64.9 ± 4.9 years) of the Spanish PREDIMED-Plus ("PREvention with MEDiterranean DIet") trial were used for this analysis. Items from the FFQ were classified according to four main food processing-based classification systems (NOVA, IARC, IFIC and UNC). Participants were classified into tertiles of HPF consumption according to each system. Using binomial logistic regression, food groups associated with agreement in the highest tertile for at least two classification systems were chosen as items for the questionnaire. ROC analysis was used to determine cut-off points for the frequency of consumption of each item, from which a score was calculated. Internal consistency of the questionnaire was assessed through exploratory factor analysis (EFA) and Cronbach's analysis, and agreement with the four classifications was assessed with weighted kappa coefficients.

RESULTS

Regression analysis identified 14 food groups (items) associated with high HPF consumption for at least two classification systems. EFA showed that items were representative contributors of a single underlying factor, the "HPF dietary pattern" (factor loadings around 0.2). We constructed a questionnaire asking about the frequency of consumption of those items. The threshold frequency of consumption was selected using ROC analysis. Comparison of the four classification systems and the sQ-HPF showed a fair to high agreement. Significant changes in lifestyle characteristics were detected across tertiles of the sQ-HPF score. Longitudinal changes in HPF consumption were also detected by the sQ-HPF, concordantly with existing classification systems.

CONCLUSIONS

We developed a practical tool to measure HPF consumption, the sQ-HPF. This may be a valuable instrument to study its relationship with NCDs.

TRIAL REGISTRATION

Retrospectively registered at the International Standard Randomized Controlled Trial Registry ( ISRCTN89898870 ) on July 24, 2014.

Role of NAFLD on the Health Related QoL Response to Lifestyle in Patients With Metabolic Syndrome: The PREDIMED Plus Cohort

OBJECTIVE

To evaluate the effect of Non-alcoholic fatty liver disease (NAFLD) status in the impact of lifestyle over Health-related quality of life (HRQoL) in patients with metabolic syndrome (MetS).

METHODS

Baseline and 1 year follow up data from the PREDIMED-plus cohort (men and women, 55-75 years old with overweight/obesity and MetS) were studied. Adherence to an energy-restricted Mediterranean Diet (er-MeDiet) and Physical Activity (PA) were assessed with a validated screeners. Hepatic steatosis index (HSI) was implemented to evaluate NAFLD while the SF-36 questionnaire provided HRQoL evaluation. Statistical analyses were performed to evaluate the influence of baseline NAFLD on HRQoL as affected by lifestyle during 1 year of follow up.

RESULTS

Data from 5205 patients with mean age of 65 years and a 48% of female participants. Adjusted linear multivariate mixed regression models showed that patients with lower probability of NAFLD (HSI < 36 points) were more responsive to er-MeDiet (β 0.64 vs β 0.05 per er-MeDiet adherence point, p< 0.01) and PA (β 0.05 vs β 0.01 per MET-h/week, p = 0.001) than those with high probability for NAFLD in terms Physical SF-36 summary in the 1 year follow up. 10 points of er-MeDiet adherence and 50 MET-h/week were thresholds for a beneficial effect of lifestyle on HRQoL physical domain in patients with lower probability of NAFLD.

CONCLUSION

The evaluation of NAFLD by the HSI index in patients with MetS might identify subjects with different prospective sensitivity to lifestyle changes in terms of physical HRQoL (http://www.isrctn.com/ISRCTN89898870).

Corrigendum: Role of NAFLD on the health related QoL response to lifestyle in patients with metabolic syndrome: The PREDIMED plus cohort

[This corrects the article DOI: 10.3389/fendo.2022.868795.].

Morbid liver manifestations are intrinsically bound to metabolic syndrome and nutrient intake based on a machine-learning cluster analysis

Metabolic syndrome (MetS) is one of the most important medical problems around the world. Identification of patient´s singular characteristic could help to reduce the clinical impact and facilitate individualized management. This study aimed to categorize MetS patients using phenotypical and clinical variables habitually collected during health check-ups of individuals considered to have high cardiovascular risk. The selected markers to categorize MetS participants included anthropometric variables as well as clinical data, biochemical parameters and prescribed pharmacological treatment. An exploratory factor analysis was carried out with a subsequent hierarchical cluster analysis using the z-scores from factor analysis. The first step identified three different factors. The first was determined by hypercholesterolemia and associated treatments, the second factor exhibited glycemic disorders and accompanying treatments and the third factor was characterized by hepatic enzymes. Subsequently four clusters of patients were identified, where cluster 1 was characterized by glucose disorders and treatments, cluster 2 presented mild MetS, cluster 3 presented exacerbated levels of hepatic enzymes and cluster 4 highlighted cholesterol and its associated treatments Interestingly, the liver status related cluster was characterized by higher protein consumption and cluster 4 with low polyunsaturated fatty acid intake. This research emphasized the potential clinical relevance of hepatic impairments in addition to MetS traditional characterization for precision and personalized management of MetS patients.

Clinical practice guidelines and consensus for the screening of breast cancer: A systematic appraisal of their quality and reporting

INTRODUCTION

Clinical practice guidelines (CPGs) and consensus statements (CSs) are being promoted to provide high-quality healthcare guidance. This systematic review has assessed the breast cancer (BC) screening CPGs and CSs quality and reporting.

METHODS

A search of bibliographic databases (MEDLINE, Embase, Web of Science, Scopus and CDSR), 12 guideline databases and 51 professional society websites was performed without language restrictions from January 2017 to June 2020, following prospective registration (Prospero no.: CRD42020203807). AGREE II (% of maximum score) and RIGHT (% of total 35 items) appraised quality and reporting individually, extracting data in duplicate; reviewer agreement was 98% and 93%, respectively.

RESULTS

Forty guidances with median overall quality and reporting 51% (interquartile range [IQR] 39-63) and 48% (IQR 35-65), respectively. Twenty-two (55%) and 20 (50%) did not reach the minimum standards (scores <50%). The guidances that deployed systematic reviews had better quality (74.2% vs. 46.9%; p = 0.001) and reporting (80.5% vs. 42.6%; p = 0.001). Guidances reporting a tool referral scored better (AGREE II: 72.8% vs. 43.1%, p = 0.002; RIGHT: 75.0% vs. 46.9%, p = 0.004).

CONCLUSION

BC screening CPGs and CSs suffered poor quality and reporting. More than half did not reach the minimum standards. They would improve if systematic reviews were used to underpin the recommendations made.