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INTRODUCTION The dietary pattern approach is useful to study the effect of the overall diet on health outcomes, through considering the network of complex interactions between foods or nutrients. The main methods traditionally used to identify dietary patterns are principal components analysis, factor analysis, principal components factor analysis and cluster analysis. Latent class analysis (LCA) is a latent variable approach, that has some advantages in comparison to the previous methods. Unlike principal component, factor and principal component factor analysis, it can be used to classify individuals into mutually exclusive groups conceived as dietary patterns and differently from cluster analysis, which has the same aim of grouping subjects, it permits quantification of the uncertainty of class membership, and assessment of goodness of fit. Moreover, it allows for adjustment for covariates directly in the pattern identification. OBJECTIVES As latent class analysis has rarely been applied in dietary pattern studies, the aim of this research is to apply the recent developments of the techniques to this area of research. We targeted to address the issue of dietary pattern identification in the case-control setting using latent class analysis and latent class trees. We provided estimation of pattern sizes and their characterization, taking into account correlations between dietary variables (local dependencies), and covariate adjustment. We also evaluated the robustness of the identified dietary patterns to total non-alcoholic energy intake adjustment, for different types of correction. Finally, we illustrated the method?s properties in the assessment of the relation between the identified dietary patterns and selected health outcomes, given the all the above. DIETARY PATTERNS AND THE RISK OF ORAL AND PHARYNGEAL CANCER We analyzed data from a multicentric case-control study on oral and pharyngeal cancer (OPC) carried out between 1992 and 2009, including 946 cases and 2492 hospital controls. Information on diet was collected through a food frequency questionnaire (FFQ). Using LCA, we identified 4 dietary patterns, conceived as mutually exclusive groups of people who shared a common dietary behaviour within groups. The first pattern, labelled ?Prudent pattern?, showed higher probability of consuming more leafy and fruiting vegetables, citrus fruit and all other kinds of fruits, tea while showing lower probability of consuming red meat. The second pattern, that we named ?Western pattern?, reported higher consumption of red meat and lower consumption of fruits, cruciferous and fruiting vegetables. We termed the third pattern ?Lower consumers-combination pattern? as people in it were less likely to eat fruits, leafy and fruiting vegetables, pulses, potatoes, fish, white and red meat, bread and tea/decaffeinated coffee. The last pattern had higher probability to eating fruiting, leafy and other vegetables, white and red meat and bread, while showed a lower probability to consume coffee, tea, processed meat, cheese, fish, sugary drinks and desserts. We called this last pattern ?Higher consumers-combination pattern?. Dietary patterns were adjusted for total non-alcoholic energy intake and correlation between certain foods item (sugar-coffee, soups-pulses) was allowed during classes identification. Compared to the Prudent pattern, the Western and the Lower consumers-combination ones were positively related to the risk of OPC (OR=2.56, 95% CI: 1.90 ? 3.45 and OR=2.23, 95% CI: 1.64 ? 3.02). Higher consumers-combination pattern didn?t differ significantly from the Prudent pattern (OR=1.28, 95% CI: 0.92 ? 1.77). ENERGY INTAKE ADJUSTMENT IN DIETARY PATTERN RESEARCH USING LATENT CLASS ANALYSIS Using data from the multicentric case-control study on OPC (Italy, 1992-2009), we identified and compared dietary patterns adjusting or not for total non-alcoholic energy intake in the classes identification phase of the analysis. Three possible ways to correct for total energy intake in class identification were presented, corresponding to different hypothesis on the effect of this variable. In general unadjusted and adjusted solutions were comparable. The main difference was related to the patterns that showed highest/lowest non-alcoholic energy intake, that resulted in a variation of number of classes (4/5/7 patterns for the different adjusted solutions and 5 patterns for the unadjusted one). Then, to determine the effect of adjustment in predicting an health outcome, we compared the effect of unadjusted dietary patterns, unadjusted dietary patterns with non-alcoholic energy intake variable also included in the model as a confounder, and adjusted dietary patterns on the risk of OPC . Differences in the estimations for the distinct solutions were found when Odds Ratios (ORs) were not corrected for known/potential risk factors. In general, adjustments for non-alcoholic energy intake results in a mitigation of the effects, thus remaining in the same order. When adjusting for known/potential risk factors, estimations of ORs and related confidence intervals (CIs) remained consistent in all the models we fitted. In the end, specific suggestions on how to perform energy correction in dietary patterns research using LCA were delivered, basing on the results of the current analysis. DIETARY PATTERNS INSPECTION THROUGH LATENT CLASS TREE We analyzed data from two Italian case?control studies, the first included 946 cases with OPC and 2492 hospital controls, and the second included 304 cases with squamous cell carcinoma of the esophagus (ESCC) and 743 hospital controls. In our application of latent class analysis on the combined dataset of the two case-control studies (Italy, 1992-2009), we found the best fit for a solution that was difficult to interpret and included minor differences between clusters. To address these issues, the Latent Class Tree method was proposed. Three fit statistics (AIC, AIC3, BIC) were used for their different level of penalty that resulted in different lengths of the tree and consequently, different granularity in the analysis. For the first split we allowed for a 4-class solution which identified a pattern characterized by high intake of leafy and fruiting vegetable and fruits (?Prudent pattern?), a pattern with a high intake of red meat and low intake of certain fruits and vegetables (?Western pattern?) and two patterns which showed a combination-type of diet. The first ?combination? pattern showed a low intake of the majority of foods (?Lower consumers-combination pattern?), and the other one high intake of various foods (?Higher consumers-combination pattern?). Compared to the Prudent pattern, the Western one was positively related to OPC (OR=1.91, 95% CI: 1.41-2.58) and to ESCC (OR=3.22, 95% CI: 1.78 ? 5.82). The Lower consumers-combination pattern was positively associated to OPC (OR=2.14, 95% CI: 1.58-2.91) and to ESCC (OR=2.85, 95% CI: 1.47-5.55). No significant association was found between the Higher consumers-combination pattern and OPC (1.04, 95% CI: 0.74-1.46) and ESCC (OR=0.89, 95% CI: 0.39-1.99). In the ?Prudent pattern? branch of the tree, at the third level, we found two classes that differed in the risk of both cancer types. These two classes differed mainly for the intake of citrus fruit, showing respectively, OR=1.85, 95% CI:1.07-3.19 for OPC and OR=5.37, 95% CI: 1.48-19.44 for ESCC for the class that reported low intake of citrus fruit with respect to the class which exhibit a high intake of citrus fruit. No other significant differences were found between the other pairs of classes at any other level of the tree. CONCLUSION We presented latent class methods as powerful tools to determine dietary patterns conceived as mutually exclusive homogeneous groups of subjects which shared common dietary habits. These methods exhibit some advantages, with respect to classical approaches, that can address important issues in dietary pattern research. For example, it is possible to obtain estimation for pattern prevalence in the population, and to perform energy intake adjustment in the pattern identification phase of the analysis. Moreover, class formation inspection, comparison between different solutions and the analysis of subgroups that may be relevant for the research at hand are features offered by the newly developed latent class tree approach.

Many applications of virtual reality appeared in different fields of the rehabilitation medicine. Nevertheless poor evidences of their effectiveness still exist. The aim of this original paper was to present the results of a retrospective analysis of 10 years of a non-immersive VR system application, for the treatment of the motor upper limb impairment in stroke patients. We observed a significant improvement in the motor outcomes, compared to standard rehabilitation, nevertheless a translation of the same effect on harder outcome such as independence wasn't observed.

Background The considerable differences in food consumption across countries pose major challenges to the research on diet and cancer, due to the difficulty to generalise and reproduce the dietary patterns identified in a specific population. Methods We analysed data from a multicentric case-control study on oesophageal squamous cell carcinoma (ESCC) carried out between 1992 and 2009 in three Italian areas and in the Canton of Vaud, Switzerland, which included 505 cases and 1259 hospital controls. Dietary patterns were derived applying LCA on 24 food groups, controlling for country membership, and non-alcoholic energy intake. A multiple logistic regression model was used to derive odds ratio (ORs) and corresponding 95% CIs for ESCC according to the dietary patterns identified, correcting for classification error. Results and Conclusion We identified three dietary patterns. The ‘Prudent’ pattern was distinguished by a diet rich in fruits and vegetables. The ‘Western’ pattern was characterised by low consumption of these food groups and higher intakes of sugar. The ‘Lower consumers-combination pattern’ exhibited a diet poor in most of the nutrients, preferences for fish, potatoes, meat and a few specific types of vegetables. Differences between Italy and Switzerland emerged for pattern sizes and for specific single food preferences. Compared to the ‘Prudent’ pattern, the ‘Western’ and the ‘Lower consumers-combination’ patterns were associated with an increased risk of ESCC (OR=3.04, 95% CI=2.12–4.38 and OR=2.81, 95% CI=1.65–4.76).

BACKGROUND: The role of allium vegetables on gastric cancer (GC) risk remains unclear. METHODS: We evaluated whether higher intakes of allium vegetables reduce GC risk using individual participant data from 17 studies participating in the "Stomach cancer Pooling (StoP) Project", including 6097 GC cases and 13,017 controls. Study-specific odds ratios (ORs) were pooled using a two-stage modelling approach. RESULTS: Total allium vegetables intake was inversely associated with GC risk. The pooled OR for the highest versus the lowest study-specific tertile of consumption was 0.71 (95% confidence interval, CI, 0.56-0.90), with substantial heterogeneity across studies (I(2) > 50%). Pooled ORs for high versus low consumption were 0.69 (95% CI, 0.55-0.86) for onions and 0.83 (95% CI, 0.75-0.93) for garlic. The inverse association with allium vegetables was evident in Asian (OR 0.50, 95% CI, 0.29-0.86) but not European (OR 0.96, 95% CI, 0.81-1.13) and American (OR 0.66, 95% CI, 0.39-1.11) studies. Results were consistent across all other strata. CONCLUSIONS: In a worldwide consortium of epidemiological studies, we found an inverse association between allium vegetables and GC, with a stronger association seen in Asian studies. The heterogeneity of results across geographic regions and possible residual confounding suggest caution in results interpretation.

The World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) introduced in 2007, and updated in 2018, nutrition-related recommendations for cancer prevention. Previous studies generally reported inverse associations of breast cancer with the 2007 recommendations, while no study has yet evaluated the association with the 2018 guidelines. We investigated the association between adherence to the 2018 WCRF/AICR recommendations and breast cancer risk in a case&ndash, control study from Italy and Switzerland (1991&ndash, 2008) including 3034 incident histologically-confirmed breast cancer cases and 3392 hospital controls. Adherence to the 2018 guidelines was summarized through a score incorporating eight recommendations (body fatness, physical activity, consumption of wholegrains/vegetables/fruit/beans, &ldquo, fast foods&rdquo, and other processed foods high in fat, starches, or sugars, red/processed meat, sugar-sweetened drinks, alcohol, breastfeeding), with higher scores indicating higher adherence. Odds ratios (OR) were estimated using multiple logistic regression models. We also conducted a meta-analysis including 15 additional studies using random-effects models. In our case&ndash, control study, adherence to the 2018 WCRF/AICR guidelines was inversely associated with breast cancer, with ORs of 0.60 (95% confidence interval (CI), 0.51&ndash, 0.70) for a score &ge, 5.5 vs. &le, 4.25, and of 0.83 (95% CI, 0.79&ndash, 0.88) for a 1-point increment. In our study, 25% of breast cancers were attributable to low-to-moderate guideline adherence. In the meta-analysis, the pooled relative risks (RRs) were 0.73 (95% CI, 0.65&ndash, 0.82, p heterogeneity among studies&lt, 0.001) for the highest vs. the lowest WCRF/AICR score category, and 0.91 (95% CI, 0.88&ndash, 0.94, p heterogeneity &lt, 0.001) for a 1-point increment. This work provides quantitative evidence that higher adherence to the WCRF/AICR recommendations reduces the risk of breast cancer, thus opening perspectives for prevention.

An internet survey was set up to assess the geriatric competence and perceived needs of 337 members of the Italian society of nephrology (SIN). The survey assessed how well aware nephrologists are of the typical geriatric conditions and needs of their elderly chronic kidney disease (CKD) patients. SIN associates were also questioned about their current use of comprehensive geriatric assessment, prescription of potentially nephrotoxic drugs, and screening for osteoporosis. The main finding is that CKD and dialysis are almost unanimously perceived as typically geriatric conditions, but knowledge and use of geriatric tools are scanty. While use of potentially inappropriate drugs is rare, almost half of the patients are not screened for osteoporosis. The significant clinical gaps observed could greatly impair the management of older CKD patients, and call for an urgent educational intervention.

Chronic kidney disease (CKD) is highly prevalent in the elderly and negatively impacts survival and health status. Thus, nephrological competence is mandatory for a skilled geriatrician. The present study aimed to assess nephrological competence in a sample of geriatricians recruited through a web survey. To this aim, a 12-items questionnaire was produced by an expert panel of nephrologists and geriatricians and was available online for members of the Italian Society of Gerontology and Geriatrics (SIGG). Two-hundred-eighty-seven geriatricians volunteered to fill in the questionnaire. The majority of them indirectly estimated the glomerular filtration rate (GFR) using mainly the Cockroft-Gault (C-G) formula. Selected nephrological exams, such as urinary Na and serum D-vitamin measurements, did not qualify as routine exams although the majority of geriatricians supplemented their patients with fat-soluble secosteroids. Ten percent of geriatricians asked for nephrological consultation only for stage 5 CKD patients and 30,9% only for stage 4 or 5. Erythropoietin supplementation was common practice for the majority of geriatricians, while only one third of them systematically used a procedure intended to prevent the contrast induced nephropathy (CIN). Finally, an alleged 50% adherence to the international guidelines for the management of CKD patients emerged from the questionnaire. Overall, results from this survey strongly recommend promoting nephrological education among geriatricians. Didactic standards for in training geriatricians need to be updated and the cooperation between geriatrics and nephrological societies promoted.