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Gholi Z, Rezaei M, Vahdat Shariatpanahi Z, Momen R, Fallah Bagher Shaidaei M, Gholami M, Aghaee S, Eskandari Sabzi H, Rajabi MR. Malnutrition elevates delirium and ICU stay among critically ill older adult COVID-19 patients. Front Med (Lausanne) 2024; 11:1259320. [PMID: 38799151 PMCID: PMC11116702 DOI: 10.3389/fmed.2024.1259320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 04/29/2024] [Indexed: 05/29/2024] Open
Abstract
Background and aim Malnutrition among intensive care unit (ICU) patients is associated with a higher risk of mortality and prolonged hospitalization. However, the influence of malnutrition on severe outcomes of ICU patients with coronavirus disease 2019 (COVID-19) is unclear. By evaluating the effect of malnutrition on the outcomes of COVID-19 in the ICU in older adult patients, this study will contribute to new knowledge of assessing the nutritional status and recovery of these patients. Methods In the current single center prospective study, 310 critically ill COVID-19 patients with an age range of ≥65 years were recruited. Data on demographic characteristics, laboratory parameters, comorbidities, medications, and types of mechanical ventilation were collected in the first 24 h of ICU admission. Malnutrition was defined based on the two-step approach of the Global Leadership Initiative on Malnutrition (GLIM) scale at baseline. During the 45 days after the baseline, we collected data on delirium incidence, mortality, invasive mechanical ventilation (IMV) requirement, length of ICU and hospital admission, and re-hospitalization. Results In this study, the prevalence of malnutrition was 63.4% among critically ill COVID-19 patients. During the 45-day follow-up, 190 (61.3%) COVID-19 deaths were recorded among the baseline 310 patients. After controlling for potential confounders, malnutrition was associated with an increased risk of delirium so malnourished COVID-19 patients had a significantly 35% higher risk of delirium than those without malnutrition (HR: 1.35, 95% CI: 1.01-1.83). Such a significant association was not for COVID-19 mortality and IMV requirement. In addition, malnutrition was associated with a significantly 84% greater odds of prolonged ICU admission (OR: 1.84, 95% CI: 1.09-3.10). No significant association was seen between malnutrition and re-hospitalization and also prolonged hospital admission. Conclusion Malnutrition was associated with an increased risk of delirium and prolonged ICU admission among critically ill older adult COVID-19 patients. Prevention, diagnosis, and treatment of malnutrition could be a key component in improving outcomes in these patients.
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Affiliation(s)
- Zahra Gholi
- Minimally Invasive Surgery Research Center; Iran University of Medical Sciences, Tehran, Iran
| | - Masoud Rezaei
- Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
- Cardiovascular Nursing Research Center, Rajaie Cardiovascular Medical and Research Center, Tehran, Iran
| | - Zahra Vahdat Shariatpanahi
- Department of Clinical Nutrition and Dietetics, National Nutrition and Food Technology Research Institute, Faculty of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Momen
- MSc in Critical Care nursing, Instructor, Critical Care Nursing Department, Faculty of Nursing, Aja University of Medical Sciences, Tehran, Iran
| | | | - Mostafa Gholami
- Nursing and Midwifery Care Research Center, Health Management Research Institute, Iran University of Medical Science, Tehran, Iran
| | - Simin Aghaee
- Department of Pediatric Nursing, School of Nursing, Student Research Committee, Yasuj University of Medical Sciences, Yasuj, Iran
| | - Hakimeh Eskandari Sabzi
- Dept. of Pediatric Nursing, School of Nursing and Midwifery, Ahvaz Jundishapour University Medical Sciences, Ahvaz, Iran, Ahvaz, Iran
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Penfold RS, Squires C, Angus A, Shenkin SD, Ibitoye T, Tieges Z, Neufeld KJ, Avelino-Silva TJ, Davis D, Anand A, Duckworth AD, Guthrie B, MacLullich AMJ. Delirium detection tools show varying completion rates and positive score rates when used at scale in routine practice in general hospital settings: A systematic review. J Am Geriatr Soc 2024; 72:1508-1524. [PMID: 38241503 DOI: 10.1111/jgs.18751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 12/11/2023] [Accepted: 12/16/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND Multiple short delirium detection tools have been validated in research studies and implemented in routine care, but there has been little study of these tools in real-world conditions. This systematic review synthesized literature reporting completion rates and/or delirium positive score rates of detection tools in large clinical populations in general hospital settings. METHODS PROSPERO (CRD42022385166). Medline, Embase, PsycINFO, CINAHL, and gray literature were searched from 1980 to December 31, 2022. Included studies or audit reports used a validated delirium detection tool performed directly with the patient as part of routine care in large clinical populations (n ≥ 1000) within a general acute hospital setting. Narrative synthesis was performed. RESULTS Twenty-two research studies and four audit reports were included. Tools used alone or in combination were the Confusion Assessment Method (CAM), 4 'A's Test (4AT), Delirium Observation Screening Scale (DOSS), Brief CAM (bCAM), Nursing Delirium Screening Scale (NuDESC), and Intensive Care Delirium Screening Checklist (ICDSC). Populations and settings varied and tools were used at different stages and frequencies in the patient journey, including on admission only; inpatient, daily or more frequently; on admission and as inpatient; inpatient post-operatively. Tool completion rates ranged from 19% to 100%. Admission positive score rates ranged from: CAM 8%-51%; 4AT 13%-20%. Inpatient positive score rates ranged from: CAM 2%-20%, DOSS 6%-42%, and NuDESC 5-13%. Postoperative positive score rates were 21% and 28% (4AT). All but two studies had moderate-high risk of bias. CONCLUSIONS This systematic review of delirium detection tool implementation in large acute patient populations found clinically important variability in tool completion rates, and in delirium positive score rates relative to expected delirium prevalence. This study highlights a need for greater reporting and analysis of relevant healthcare systems data. This is vital to advance understanding of effective delirium detection in routine care.
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Affiliation(s)
- Rose S Penfold
- Edinburgh Delirium Research Group, Ageing and Health and Advanced Care Research Centre, Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | | | - Susan D Shenkin
- Edinburgh Delirium Research Group, Ageing and Health and Advanced Care Research Centre, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Temi Ibitoye
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Zoë Tieges
- School of Computing, Engineering and Built Environment, Glasgow Caledonian University, Glasgow, UK
| | - Karin J Neufeld
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing, UCL, London, UK
| | - Atul Anand
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - Bruce Guthrie
- Advanced Care Research Centre, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
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Fluck D, Lisk R, Yeong K, Mahmood R, Robin J, Fry CH, Han TS. Sex differences in clinical outcomes amongst 1105 patients admitted with hip fractures. Intern Emerg Med 2023; 18:1561-1568. [PMID: 37101056 DOI: 10.1007/s11739-023-03264-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 03/31/2023] [Indexed: 04/28/2023]
Abstract
Amongst hip fracture admissions, mortality is higher in men than in women. However, sex differences in other care-quality measures have not been well-documented. We aimed to examine sex differences in mortality as well as a wide range of underlying health indicators and clinical outcomes in adults ≥ 60 year of age admitted with hip fractures from their own homes to a single NHS hospital between April-2009 and June-2019. Sex differences in delirium, length of stay (LOS) and mortality in hospital, readmission, and discharge destination, were examined by logistic regression. There were 787 women and 318 men of similar mean age (± SD): 83.1 year (± 8.6) and 82.5 year (± 9.0), respectively (P = 0.269). There were no sex differences in history of dementia or diabetes, anticholinergic burden, pre-fracture physical function, American Society of Anesthesiologists grades, or surgical and medical management. Stroke and ischaemic heart disease, polypharmacy, and alcohol consumption were more common in men. After adjustment for these differences and age, men had greater risk of delirium (with or without cognitive impairment) within one day of surgery: OR = 1.75 (95%CI 1.14-2.68), LOS ≥ 3 weeks in hospital: OR = 1.52 (1.07-2.16), mortality in hospital: OR = 2.04 (1.14-3.64), and readmission once or more after 30 days of a discharge: OR = 1.53 (1.03-2.31). Men had a lower risk of a new discharge to residential/nursing care: OR = 0.46 (0.23-0.93). The present study revealed that, in addition to a greater risk of mortality than women, men also had many other adverse health outcomes. These findings, which have not been well-documented, serve to stimulate future targeted preventive strategies and research.
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Affiliation(s)
- David Fluck
- Department of Cardiology, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, KT16 0PZ, Surrey, UK
| | - Radcliffe Lisk
- Department of Orthopaedic Trauma, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, KT16 0PZ, Surrey, UK
| | - Keefai Yeong
- Department of Orthopaedic Trauma, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, KT16 0PZ, Surrey, UK
| | - Rashid Mahmood
- Department of Orthopaedic Trauma, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, KT16 0PZ, Surrey, UK
| | - Jonathan Robin
- Department of Acute Medicine, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, KT16 0PZ, Surrey, UK
| | - Christopher Henry Fry
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, BS8 1TD, UK
| | - Thang Sieu Han
- Department of Endocrinology, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, KT16 0PZ, Surrey, UK.
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, TW20 0EX, Surrey, UK.
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Fluck D, Fry CH, Rankin S, Gulli G, Affley B, Robin J, Kakar P, Sharma P, Han TS. Comparison of characteristics, management and outcomes in hospital-onset and community-onset stroke: a multi-centre registry-based cohort study of acute stroke. Neurol Sci 2022; 43:4853-4862. [PMID: 35322338 PMCID: PMC9349089 DOI: 10.1007/s10072-022-06015-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/15/2022] [Indexed: 11/28/2022]
Abstract
Abstract
Objective
Hospital-onset stroke (HOS) is associated with poorer outcomes than community-onset stroke (COS). Previous studies have variably documented patient characteristics and outcome measures; here, we compare in detail characteristics, management and outcomes of HOS and COS.
Methods
A total of 1656 men (mean age ± SD = 73.1 years ± 13.2) and 1653 women (79.3 years ± 13.0), with data prospectively collected (2014–2016) from the Sentinel Stroke National Audit Programme, were admitted with acute stroke in four UK hyperacute stroke units (HASU). Associations between variables were examined by chi-squared tests and multivariable logistic regression (COS as reference).
Results
There were 272 HOS and 3037 COS patients with mean ages of 80.2 years ± 12.5 and 76.4 years ± SD13.5 and equal sex distribution. Compared to COS, HOS had higher proportions ≥ 80 years (64.0% vs 46.4%), congestive heart failure (16.9% vs 4.9%), atrial fibrillation (25.0% vs 19.7%) and pre-stroke disability (9.6% vs 5.1%), and similar history of stroke, hypertension, diabetes, stroke type and severity of stroke. After age, sex and co-morbidities adjustments, HOS had greater risk of pneumonia: OR (95%CI) = 1.9 (1.3–2.6); malnutrition: OR = 2.2 (1.7–2.9); immediate thrombolysis complications: OR = 5.3 (1.5–18.2); length of stay on HASU > 3 weeks: OR = 2.5 (1.8–3.4); post-stroke disability: OR = 1.8 (1.4–2.4); and in-hospital mortality: OR = 1.8 (1.2–2.4), as well as greater support at discharge including palliative care: OR = 1.9 (1.3–2.8); nursing care: OR = 2.0 (1.3–4.0), help for daily living activities: OR = 1.6 (1.1–2.2); and joint-care planning: OR = 1.5 (1.1–1.9).
Conclusions
This detailed analysis of underlying differences in subject characteristics between patients with HOS or COS and adverse consequences provides further insights into understanding poorer outcomes associated with HOS.
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Affiliation(s)
- David Fluck
- Department of Cardiology, Ashford and St Peter’s NHS Foundation Trust, Chertsey, GU9 0PZ UK
| | - Christopher H. Fry
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, BS8 1TD UK
| | - Suzanne Rankin
- Department of Cardiology, Ashford and St Peter’s NHS Foundation Trust, Chertsey, GU9 0PZ UK
| | - Giosue Gulli
- Department of Stroke, Ashford and St Peter’s NHS Foundation Trust, Chertsey, GU9 0PZ UK
| | - Brendan Affley
- Department of Stroke, Ashford and St Peter’s NHS Foundation Trust, Chertsey, GU9 0PZ UK
| | - Jonathan Robin
- Department of Acute Medicine, Ashford and St Peter’s NHS Foundation Trust, Chertsey, GU9 0PZ UK
| | - Puneet Kakar
- Department of Stroke, Epsom and St Helier University Hospitals, Epsom, KT18 7EG UK
| | - Pankaj Sharma
- Department of Clinical Neuroscience, Imperial College Healthcare NHS Trust, London, W6 8RF UK
- Institute of Cardiovascular Research, Royal Holloway University of London, Egham, TW20 0EX UK
| | - Thang S. Han
- Institute of Cardiovascular Research, Royal Holloway University of London, Egham, TW20 0EX UK
- Department of Endocrinology, Ashford and St Peter’s NHS Foundation Trust, Chertsey, GU9 0PZ UK
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Kupisz-Urbanska M, Marcinowska-Suchowierska E. Malnutrition in Older Adults—Effect on Falls and Fractures: A Narrative Review. Nutrients 2022; 14:nu14153123. [PMID: 35956299 PMCID: PMC9370498 DOI: 10.3390/nu14153123] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 07/26/2022] [Indexed: 12/10/2022] Open
Abstract
Malnutrition in older adults impacts health status, increased mortality, and morbidity. Malnutrition may increase the development of geriatric syndromes and contribute to a higher prevalence of falls and osteoporotic fractures that lead to loss of independence and an increased rate of institutionalization. The role of malnutrition in the pathogenesis of other geriatric syndromes seems to be well established. However, the data concerning nutritional interventions are confounding. Moreover, long-term undernutrition seems to be one of the factors that strongly influences the efficacy of interventions. This review outlines the current literature on this topic, and aims to guide physicians to make proper decisions to prevent the vicious cycle of falls, fractures, and their negative outcomes in patients with malnutrition.
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Affiliation(s)
- Malgorzata Kupisz-Urbanska
- Department of Geriatrics, Centre of Postgraduate Medical Education, 02-673 Warsaw, Poland
- Correspondence:
| | - Ewa Marcinowska-Suchowierska
- Department of Internal Medicine and Geriatric Cardiology, Centre of Postgraduate Medical Education, 02-673 Warsaw, Poland;
- Department of Geriatrics and Gerontology, School of Public Health, Medical Centre of Postgraduate Education, 02-673 Warsaw, Poland
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Han TS, Fry CH, Fluck D, Gulli G, Affley B, Robin J, Kakar P, Sharma P. Predicting Stroke Complications in Hospital and Functional Status at Discharge by Clustering of Cardiovascular Diseases a Multi-Centre Registry-Based Study of Acute Stroke. J Stroke Cerebrovasc Dis 2021; 31:106162. [PMID: 34689050 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/25/2021] [Accepted: 10/03/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE Indicators for outcomes following acute stroke are lacking. We have developed novel evidence-based criteria for identifying outcomes of acute stroke using the presence of clusters of coexisting cardiovascular disease (CVD). MATERIALS AND METHODS Analysis of prospectively collected data from the Sentinel Stroke National Audit Programme (SSNAP). A total of 1656 men (mean age ±SD=73.1yrs±13.2) and 1653 women (79.3yrs±13.0) were admitted with acute stroke (83.3% ischaemic, 15.7% intracranial haemorrhagic), 1.0% unspecified) in four major UK hyperacute stroke units (HASU) between 2014 and 2016. Four categories from cardiovascular disease Congestive heart failure, Atrial fibrillation, pre-existing Stroke and Hypertension (CASH).were constructed: CASH-0 (no coexisting CVD); CASH-1 (any one coexisting CVD); CASH-2 (any two coexisting CVD); CASH-3 (any three or all four coexisting CVD). These were tested against outcomes, adjusted for age and sex. RESULTS Compared to CASH-0, individuals with CASH-3 had greatest risks of in-hospital mortality (11.1% vs 24.5%, OR=1.8, 95%CI=1.3-2.7) and disability (modified Rankin Scale score ≥4) at discharge (24.2% vs 46.2%, OR=1.9, 95%CI=1.4-2.7), urinary tract infection (3.8% vs 14.6%, OR= 3.3, 95%CI= 1.9-5.5), and pneumonia (7.1% vs 20.6%, OR= 2.6, 95%CI= 1.7-4.0); length of stay on HASU >14 days (29.8% vs 39.3%, OR=1.8, 95%CI=1.3-2.6); and joint-care planning (20.9% vs 29.8%, OR=1.4, 95%CI=1.0-2.0). CONCLUSIONS We present a simple tool for estimating the risk of adverse outcomes of acute stroke including death, disability at discharge, nosocomial infections, prolonged length of stay, as well as any joint care planning. CASH-0 indicates a low level and CASH-3 indicates a high level of risk of such complications after stroke.
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Affiliation(s)
- Thang S Han
- Institute of Cardiovascular Research, Royal Holloway University of London, Egham, TW20 0EX, UK.
| | - Christopher H Fry
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, BS8 1TD UK.
| | - David Fluck
- Department of Cardiology, Ashford and St Peter's NHS Foundation Trust, Chertsey, GU9 0PZ, UK.
| | - Giosue Gulli
- Department of Stroke, Ashford and St Peter's NHS Foundation Trust, Chertsey, GU9 0PZ, UK.
| | - Brendan Affley
- Department of Stroke, Ashford and St Peter's NHS Foundation Trust, Chertsey, GU9 0PZ, UK.
| | - Jonathan Robin
- Department of Acute Medicine, Ashford and St Peter's NHS Foundation Trust, Chertsey, GU9 0PZ, UK.
| | - Puneet Kakar
- Department of Stroke, Epsom and St Helier University Hospitals, Epsom KT18 7EG, UK.
| | - Pankaj Sharma
- Institute of Cardiovascular Research, Royal Holloway University of London, Egham, TW20 0EX, UK; Department of Clinical Neuroscience, Imperial College Healthcare NHS Trust, London W6 8RF, UK.
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Fluck D, Fry CH, Gulli G, Affley B, Robin J, Kakar P, Sharma P, Han TS. Association of risk of malnutrition with adverse outcomes and early support on discharge in acute stroke patients without prestroke disability: A multicenter, registry-based cohort study. Nutr Clin Pract 2021; 37:1233-1241. [PMID: 34664741 DOI: 10.1002/ncp.10790] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Malnutrition in hospitals remains highly prevalent. As part of quality improvement initiatives, the Royal College of Physicians recommends nutrition screening for all patients admitted with acute stroke. We aimed to examine the associations of patients at risk of malnutrition with poststroke outcomes. METHODS We analyzed prospectively collected data from four hyperacute stroke units (HASUs) (2014-2016). Nutrition status was screened in 2962 acute stroke patients without prestroke disability (1515 men, [mean ± SD] 73.5 years ± 13.1; 1447 women, 79.2 ± 13.0 years). The risk of malnutrition was tested against stroke outcomes and adjusted for age, sex, and comorbidities. RESULTS Risk of malnutrition was identified in 25.8% of patients). Compared with well-nourished patients, those at risk of malnutrition had, within 7 days of admission, increased risk of stay on the HASU of >14 days (odds ratio [OR]: 9.9 [7.3-11.5]), disability on discharge (OR: 8.1 [6.6-10.0]), worst level of consciousness in the first 7 days (score ≥ 1) (OR: 7.5 [6.1-9.3]), mortality (OR: 5.2 [4.0-6.6], pneumonia (OR: 5.1 [3.9-6.7]), and urinary tract infection (OR: 1.5 [1.1-2.0]). They also required palliative care (OR: 12.3 [8.5-17.8]), discharge to new care home (OR: 3.07 [2.18-4.3]), activities of daily living support (OR: 1.8 [1.5-2.3]), planned joint care (OR: 1.5 [1.2-1.8]), and weekly visits (OR: 1.4 [1.1-1.8]). CONCLUSION Patients at risk of malnutrition more commonly have multiple adverse outcomes after acute stroke and greater need for early support on discharge.
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Affiliation(s)
- David Fluck
- Department of Cardiology, Ashford and St Peter's NHS Foundation Trust, Chertsey, UK
| | - Christopher H Fry
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
| | - Giosue Gulli
- Department of Stroke, Ashford and St Peter's NHS Foundation Trust, Chertsey, UK
| | - Brendan Affley
- Department of Stroke, Ashford and St Peter's NHS Foundation Trust, Chertsey, UK
| | - Jonathan Robin
- Department of Acute Medicine, Ashford and St Peter's NHS Foundation Trust, Chertsey, UK
| | - Puneet Kakar
- Department of Stroke, Epsom and St Helier University Hospitals, Epsom, UK
| | - Pankaj Sharma
- Institute of Cardiovascular Research, Royal Holloway University of London, Egham, UK.,Department of Clinical Neuroscience, Imperial College Healthcare NHS Trust, London, UK
| | - Thang S Han
- Institute of Cardiovascular Research, Royal Holloway University of London, Egham, UK
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