Guideline implementation, drug sequencing, and quality of care in heart failure:design and rationale of TITRATE-HF

Aims: Current heart failure (HF) guidelines recommend to prescribe four drug classes in patients with HF with reduced ejection fraction (HFrEF). A clear challenge exists to adequately implement guideline-directed medical therapy (GDMT) regarding the sequencing of drugs and timely reaching target dose. It is largely unknown how the paradigm shift from a serial and sequential approach for drug therapy to early parallel application of the four drug classes will be executed in daily clinical practice, as well as the reason clinicians may not adhere to new guidelines. We present the design and rationale for the real-world TITRATE-HF study, which aims to assess sequencing strategies for GDMT initiation, dose titration patterns (order and speed), intolerance for GDMT, barriers for implementation, and long-term outcomes in patients with de novo, chronic, and worsening HF. Methods and results: A total of 4000 patients with HFrEF, HF with mildly reduced ejection fraction, and HF with improved ejection fraction will be enrolled in &gt;40 Dutch centres with a follow-up of at least 3 years. Data collection will include demographics, physical examination and vital parameters, electrocardiogram, laboratory measurements, echocardiogram, medication, and quality of life. Detailed information on titration steps will be collected for the four GDMT drug classes. Information will include date, primary reason for change, and potential intolerances. The primary clinical endpoints are HF-related hospitalizations, HF-related urgent visits with a need for intravenous diuretics, all-cause mortality, and cardiovascular mortality. Conclusions: TITRATE-HF is a real-world multicentre longitudinal registry that will provide unique information on contemporary GDMT implementation, sequencing strategies (order and speed), and prognosis in de novo, worsening, and chronic HF patients.</p

Sensitivity to Experiencing Alcohol Hangovers: Reconsideration of the 0.11% Blood Alcohol Concentration (BAC) Threshold for Having a Hangover

The 2010 Alcohol Hangover Research Group consensus paper defined a cutoff blood alcohol concentration (BAC) of 0.11% as a toxicological threshold indicating that sufficient alcohol had been consumed to develop a hangover. The cutoff was based on previous research and applied mostly in studies comprising student samples. Previously, we showed that sensitivity to hangovers depends on (estimated) BAC during acute intoxication, with a greater percentage of drinkers reporting hangovers at higher BAC levels. However, a substantial number of participants also reported hangovers at comparatively lower BAC levels. This calls the suitability of the 0.11% threshold into question. Recent research has shown that subjective intoxication, i.e., the level of severity of reported drunkenness, and not BAC, is the most important determinant of hangover severity. Non-student samples often have a much lower alcohol intake compared to student samples, and overall BACs often remain below 0.11%. Despite these lower BACs, many non-student participants report having a hangover, especially when their subjective intoxication levels are high. This may be the case when alcohol consumption on the drinking occasion that results in a hangover significantly exceeds their “normal” drinking level, irrespective of whether they meet the 0.11% threshold in any of these conditions. Whereas consumers may have relative tolerance to the adverse effects at their “regular” drinking level, considerably higher alcohol intake—irrespective of the absolute amount—may consequentially result in a next-day hangover. Taken together, these findings suggest that the 0.11% threshold value as a criterion for having a hangover should be abandoned

Using implicit rather than explicit measures of emotions

Implicit and explicit measures are typically combined in laboratory food studies. Results of these laboratory studies often show little additional value of implicit compared to explicit measures. We argue that implicit measures of food experience should not be regarded as a more expensive and more complex equivalent of established explicit measures. Instead, each type of measure provides complementary information. Whereas explicit measures capture especially the sensory aspects of the food itself, implicit measures capture especially the total food experience from pre- to post- consumption, which not only relates to the food itself but also to factors such as the physical and social context in which foods are consumed in real life. This requires that implicit measures are applied outside the conventional laboratory habitat. Fortunately, this becomes increasingly possible with current technical developments.</p

Effect of cross-cultural differences on thickness, firmness and sweetness sensitivity

Sensitivity of the somatosensory system may be influenced by multiple physiological parameters. Variations in oral physiology can arise from cross-cultural differences which may potentially affect sensory sensitivity. The aim of this case study was to quantify texture and taste sensitivity in Dutch (Caucasian) and Chinese (Asian) adults living in the Netherlands. Eighty-five healthy subjects were recruited including 44 Dutch (Caucasian) adults (29 females, 22.8 ± 2.3 yrs) and 41 Chinese (Asian) adults (30 females, 24.5 ± 2.1 yrs) living in the Netherlands for less than 1 year. Three sets of stimuli were used to quantify sensitivity of thickness (maltodextrin solutions differing in viscosity), firmness (agar gels differing in fracture stress) and sweetness (sucrose solutions differing in concentration). The 2-Alternative Forced Choice (2-AFC) ascending staircase method was used to determine texture and taste sensitivity. Unstimulated and stimulated saliva flow rate, fungiform papillae density (FPD), lingual tactile threshold and PROP taster status were determined and are referred to as physiological and sensory consumer characteristics. No significant differences were observed between Chinese and Dutch adults for thickness (Dutch 2.60 mPas, Chinese 2.19 mPas), firmness (Dutch 10.5 kPa, Chinese 10.3 kPa) and sweetness sensitivity (Dutch 0.012 g/mL, Chinese 0.017 g/mL). No significant differences were observed between Chinese and Dutch adults for saliva flow rate, lingual tactile threshold and PROP taster status. The relationships between the three sensory sensitivities (thickness, firmness, sweetness) and five physiological and sensory consumer characteristics (unstimulated and stimulated saliva flow rate, FPD, lingual tactile threshold, PROP taster status) were analyzed. Only one out of 15 relationships, firmness sensitivity and FPD, was significantly and weakly related suggesting that inter-individual variation in these consumer characteristics is almost unrelated to sensory sensitivity. We conclude that in this case study thickness, firmness and sweetness sensitivities do not differ between Dutch and Chinese adults living in the Netherlands. Saliva flow rate, fungiform papillae density, lingual tactile threshold and PROP taster status do not explain inter-individual variation in sensory sensitivity between these consumers.</p

Sensory-specific satiety: Added insights from autonomic nervous system responses and facial expressions

As a food is consumed, its perceived pleasantness declines compared to that of other foods. Although this phenomenon, referred to as sensory-specific satiety, is well-established by means of measuring food intake and pleasantness ratings, this study was aimed at gaining more insight into the mechanisms that underlie such cognitive output behavior using two measures used in (food) emotion research, namely Autonomic Nervous System (ANS) responses and facial expressions. Twenty-four healthy female participants visited four times in a hungry state, in which they received 4 different semi-liquid meals (2 sweet and 2 savory) delivered via a time-controlled pump leading to sensory-specific satiety. Before and after the meals they were presented with a sip of all four different test meals where ANS responses (heart rate, skin conductance and skin temperature) and facial expressions were recorded. As expected, pleasantness ratings showed a significant decrease after eating the same meal or a meal similar in taste (sweet or savory) (p < 0.001), and less decrease after eating a meal with a different taste. In general, consumption of the test meals resulted in increased heart rate, reduced skin conductance and skin temperature, as well as intensified anger and disgusted facial expressions (p < 0.05). In addition, skin conductance, skin temperature, sad and angry expressions also showed effects reflecting sensory-specific satiety. In conclusion, ANS responses and facial expressions indicate that sensory specific satiety of foods 1) not only reduces the food's pleasantness but also arousal and 2) are possibly mediated by changes in food emotions

"Welcome on board" : Overall liking and just-about-right ratings of airplane meals in three different consumption contexts-laboratory, re-created airplane, and actual airplane

The main objective of this study was to evaluate the effect of contexts on overall liking and just-about-right (JAR) ratings of airplane meals. A rice dish (meal type A) and a pasta dish (meal type B) were assessed. Per meal type, two variants were produced (variant 1 and 2). Two hundred forty-two consumers were randomly allocated to evaluate one of the four meals, first in a laboratory setting and then in a re-created airplane environment. In addition, 222 passengers did the same assessments during an actual flight. Specific meals (A1, B1) were less liked in the laboratory than in the re-created airplane. In general, no differentiation in overall liking occurred per meal type between the two tested variants in the laboratory, whereas these two variants were significantly differentiated in liking in the re-created airplane and the actual airplane. Mean overall liking ratings in the re-created airplane did not significantly differ from the mean overall liking ratings in the actual airplane. The observed JAR ratings did not differ much between the re-created airplane and the actual airplane. In summary, the re-created airplane as a testing location produced more similar test results to the actual airplane than the traditional laboratory. Practical applications: Sensory consumer testing in re-created contexts may produce results with a higher external validity than laboratory testing and therefore offer a cost-efficient alternative to extensive sensory consumer testing in real-life contexts.</p

"Welcome on board" : Overall liking and just-about-right ratings of airplane meals in three different consumption contexts-laboratory, re-created airplane, and actual airplane

The main objective of this study was to evaluate the effect of contexts on overall liking and just-about-right (JAR) ratings of airplane meals. A rice dish (meal type A) and a pasta dish (meal type B) were assessed. Per meal type, two variants were produced (variant 1 and 2). Two hundred forty-two consumers were randomly allocated to evaluate one of the four meals, first in a laboratory setting and then in a re-created airplane environment. In addition, 222 passengers did the same assessments during an actual flight. Specific meals (A1, B1) were less liked in the laboratory than in the re-created airplane. In general, no differentiation in overall liking occurred per meal type between the two tested variants in the laboratory, whereas these two variants were significantly differentiated in liking in the re-created airplane and the actual airplane. Mean overall liking ratings in the re-created airplane did not significantly differ from the mean overall liking ratings in the actual airplane. The observed JAR ratings did not differ much between the re-created airplane and the actual airplane. In summary, the re-created airplane as a testing location produced more similar test results to the actual airplane than the traditional laboratory. Practical applications: Sensory consumer testing in re-created contexts may produce results with a higher external validity than laboratory testing and therefore offer a cost-efficient alternative to extensive sensory consumer testing in real-life contexts.</p

ANS responses and facial expressions differentiate between the taste of commercial breakfast drinks.

The high failure rate of new market introductions, despite initial successful testing with traditional sensory and consumer tests, necessitates the development of other tests. This study explored the ability of selected physiological and behavioral measures of the autonomic nervous system (ANS) to distinguish between repeated exposures to foods from a single category (breakfast drinks) and with similar liking ratings. In this within-subject study 19 healthy young adults sipped from five breakfast drinks, each presented five times, while ANS responses (heart rate, skin conductance response and skin temperature), facial expressions, liking, and intensities were recorded. The results showed that liking was associated with increased heart rate and skin temperature, and more neutral facial expressions. Intensity was associated with reduced heart rate and skin temperature, more neutral expressions and more negative expressions of sadness, anger and surprise. Strongest associations with liking were found after 1 second of tasting, whereas strongest associations with intensity were found after 2 seconds of tasting. Future studies should verify the contribution of the additional information to the prediction of market success