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Rationale: Complexity is increasingly recognized as a critical variable in health care. However, there is still lack of practical tools to assess it and tackle the challenges that stem from it, particularly within hospitals. Aims and objective:To validate a simple novel screening method based on both objective and subjective criteria to identify patients with clinically complex hospitalization events. To evaluate the prevalence of patients with complex events, identify their features, and compare them with those of the other patients and to those of patients with multimorbidities. Method:We monitored the level of complexity of the hospitalization events of 240 patients admitted to an internal medicine ward in Tuscany over the course of 56 days. We compared the demographic features, the length of stay, and the prognosis of patients with and without complex events. Results:Sixty-nine patients (28.8% of the sample) had a complex episode during their stay, and 115 (47.9%) had phases of low complexity. Patients with complex episodes were younger and more comorbid than patients without. They stayed longer in-hospital (+4.5 days; 95% CI: 2.5-6.5) and had higher mortality (OR: 24.93;) and a lower probability of home discharge (OR: 0.25; 95% CI: 0.13-0.48). Conclusions:The results show that using a simple screening method is possible to identify complex patients within IM wards and that every day, about one-third of the patients are complex. The results are discussed in implications for the dynamic management of patients with complex and simple phases during hospitalization. KEYWORDSclinical complexity, internal medicine, measurement tools, multimorbidityThis is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. for a simple problem (eg, pneumonia) with a predictable and definite path/outcome. Therefore, using multimorbidity to identify complex patients also suffers from low specificity, which would seem particularly undesirable given the extremely high, and exponentially growing, prevalence of this condition today. 11Complexity is a property of systems with a high number of components, interacting dynamically and nonlinearly at multiple levels, also through feedback loops, so that the evolution of the system is not predictable. In a patient, therefore, complexity can be seen as the 15 Conducting an assessment with this method, however, requires a specific training and takes an amount of time that, though limited (15-20 min), could make it difficult to use in practice in a strongly time-constrained setting such as an internal medicine ward.In the light of these problems with defining and measuring complexity, and to develop solutions for managing it, it might be useful to expand the focus from the complexity of the patients to the one of the tasks carried out by professionals in providing health care for patients. Clin...

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The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl

Strategies to improve doctor-patient communication may have a beneficial impact on patient's illness experience and mood, with potential favorable clinical effects. We prospectively tested the psychometric and clinical validity of the Decalogue, a tool utilizing 10 communication recommendations for patients and physicians. The Decalogue was administered to 100 consecutive patients referred for a cardiologic consultation, whereas 49 patients served as controls. The POMS-2 questionnaire was used to measure the total mood disturbance at the end of the consultation. Structural equation modeling showed high internal consistency (Cronbach alpha 0.93), good test-retest reproducibility, and high validity of the psychometric construct (all > 0.80), suggesting a positive effect on patients' illness experience. The total mood disturbance was lower in the patients exposed to the Decalogue as compared to the controls (1.4 ± 12.1 versus 14.8 ± 27.6, p = 0.0010). In an additional questionnaire, patients in the Decalogue group showed a trend towards a better understanding of their state of health (p = 0.07). In a cardiologic ambulatory setting, the Decalogue shows good validity and reliability as a tool to improve patients' illness experience and could have a favorable impact on mood states. These effects might potentially improve patient engagement in care and adherence to therapy, as well as clinical outcome.

Plant Biostimulants (BSs) are a valid supplement to be considered for the integration of conventional fertilization practices. Research in the BS field keeps providing alternative products of various origin, which can be employed in organic and conventional agriculture. In this study, we investigated the biostimulant activity of the eluate obtained as a by-product from the industrial production of lactic acid bacteria on bare agricultural soil. Eluates utilization is in line with the circular economy principle, creating economical value for an industrial waste product. The research focused on the study of physical, chemical, biochemical, and microbiological changes occurring in agricultural soil treated with the biowaste eluate, applied at three different dosages. The final aim was to demonstrate if, and to what extent, the application of the eluate improved soil quality parameters and enhanced the presence of beneficial soil-borne microbial communities. Results indicate that a single application at the two lower dosages does not have a pronounced effect on the soil chemical parameters tested, and neither on the biochemical proprieties. Only the higher dosage applied reported an improvement in the enzymatic activities of β-glucosidase and urease and in the chemical composition, showing a higher content of total, nitric and ammonia N, total K, and higher humification rate. On the other hand, microbial communities were strongly influenced at all dosages, showing a decrease in the bacterial biodiversity and an increase in the fungal biodiversity. Bioinformatic analysis revealed that some Operative Taxonomic Units (OTUs) promoted by the eluate application, belong to known plant growth promoting microbes. Some other OTUs, negatively influenced were attributed to known plant pathogens, mainly Fusarium spp. Finally, the ecotoxicological parameters were also determined and allowed to establish that no toxic effect occurred upon eluate applications onto soil.

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