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Williams JP, Debski ND, Lau LX, Kooragayala K, Hunter KM, Hong YK. Advance care planning for patients undergoing gastrostomy tube procedures; prevalence, outcomes, and disparities. Am J Surg 2024; 233:4-9. [PMID: 38071139 DOI: 10.1016/j.amjsurg.2023.11.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 10/24/2023] [Accepted: 11/27/2023] [Indexed: 06/12/2024]
Abstract
BACKGROUND Advanced care planning (ACP) is the process of establishing goals for end-of-life care. We aimed to examine ACP's prevalence, associated factors, and impact in a cohort of patients undergoing gastrostomy tube procedures. METHODS Adult patients who underwent gastrostomy tube placement from 2016 to 2021 at a tertiary center were identified. Variables evaluated included age, sex, race, comorbidities, and median income of patient home zip code. Primary outcomes included the presence of ACP, length of stay (LOS), and 90-day mortality. Analysis was performed using independent T tests, Mann Whitney U-tests, and Chi Square analysis. ACP, LOS, and 90-day mortality were analyzed with multivariate analysis. RESULTS 877 patients underwent gastrostomy tube placement and 10.6 % had ACP. Black race was an isolated factor negatively associated with ACP (OR 0.423, p = 0.013). There was no difference in the proportion of patients with or without ACP who died within 90 days of the procedure (17 % vs. 15 %, p = 0.836). Average LOS was 6 days shorter for patients with ACP (p < 0.001). CONCLUSION This study highlights the significant underutilization and racial disparity in ACP, and found that ACP does not negatively impact outcomes or perioperative mortality for patients undergoing gastrostomy tube placement.
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Affiliation(s)
- Jennifer P Williams
- Department of Surgery, Cooper University Hospital Medical Center, Camden, NJ, USA.
| | | | - Lucinda X Lau
- Cooper Medical School at Rowan University, Camden, NJ, USA
| | - Keshav Kooragayala
- Department of Surgery, Cooper University Hospital Medical Center, Camden, NJ, USA
| | | | - Young K Hong
- Department of Surgery, Cooper University Hospital Medical Center, Camden, NJ, USA
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Bains K, Kalra S, Singh I, Patel J, Kohli I, Dhiman M, Dukovic D, Sohal A, Aggarwal A. Prevalence and Impact of Malnutrition in Hospitalizations Among Celiac Diseases: A Nationwide Analysis. Cureus 2023; 15:e44247. [PMID: 37772221 PMCID: PMC10524785 DOI: 10.7759/cureus.44247] [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] [Accepted: 08/28/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND/AIMS Celiac disease (CD) is a T-cell-mediated gluten sensitivity that results in villous atrophy in the small intestine, leading to chronic malabsorption. Patients with celiac disease are prone to malnutrition. We assessed the impact of malnutrition on in-hospital outcomes in patients with CD. MATERIALS AND METHODS Patients with a primary discharge diagnosis of CD between January 2016 and December 2019 were included in the National Inpatient Sample Database. Data were collected on patient demographics, hospital characteristics, the Charlson Comorbidity Index (CCI), and concomitant comorbidities. The association between malnutrition and outcomes, including mortality, deep vein thrombosis (DVT), pulmonary embolism (PE), sepsis, acute kidney injury (AKI), length of stay (LOS), and total hospitalization charges (THC), was analyzed using the multivariate regression model. RESULTS A total of 187310 patients with CD were included in the analysis. Patients with CD and malnutrition had a higher risk of mortality (adjusted odds ratio [aOR], 2.08; p<0.001), AKI (aOR=1.18, p=0.003), and DVT (aOR=1.53; p<0.001) compared to patients with CD without malnutrition. No significant difference was noted in the rates of sepsis and PE. Patients with malnutrition also had a prolonged LOS (2.89 days; p<0.001) and higher THC ($22252.18; p<0.001) compared to patients without malnutrition. DISCUSSION Patients with CD and malnutrition are at high risk of worse outcomes. Early identification of malnutrition in CD can help prevent morbidity and mortality. Even strict adherence to a gluten-free diet has been associated with malnutrition. Further studies identifying factors associated with malnutrition in CD and the impact of interventions to prevent and treat malnutrition are encouraged.
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Affiliation(s)
- Kanwal Bains
- Internal Medicine, University of Arizona College of Medicine, Tucson, USA
| | - Shivam Kalra
- Internal Medicine, Trident Medical Center, North Charleston, USA
- Internal Medicine, Dayanand Medical College and Hospital, Ludhiana, IND
| | - Ishandeep Singh
- Internal Medicine, Dayanand Medical College and Hospital, Ludhiana, IND
| | - Jay Patel
- Internal Medicine, Orange Park Medical Center, Orange Park, USA
| | - Isha Kohli
- Public Health Sciences, Icahn School of Medicine at Mount Sinai, New York City, USA
| | - Mukul Dhiman
- Internal Medicine, Punjab Institute of Medical Sciences, Jalandhar, IND
| | - Dino Dukovic
- Internal Medicine, Ross University School of Medicine, Bridgetown, BRB
| | - Aalam Sohal
- Hepatology, Liver Institute Northwest, Seattle, USA
| | - Avin Aggarwal
- Gastroenterology and Hepatology, University of Arizona, Tucson, USA
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3
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Marom P, Rayyan-Assi H, Stein-Reisner O, Brik M, Gershoni-Kait M, Bornstein L, Zalcman BG, Albukrek D, Dankner R. High variation between healthcare professionals in nutrition therapy plans of patients with feeding tubes admitted to a long-term rehabilitation center from an acute-care hospital. Nutr Clin Pract 2023; 38:425-433. [PMID: 36161357 DOI: 10.1002/ncp.10910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/25/2022] [Accepted: 08/28/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Nutrition therapy plans (NTPs) in discharge summaries of tube-fed patients transferred from acute-care hospitals to rehabilitation centers are fundamental for continuity of care. This study examined the presence and quality of NTPs in discharge summaries of tube-fed patients. METHODS This cross-sectional study was based on data retrieved from electronic medical records. The outcome measures were the presence of NTPs in discharge summaries, the presence of key elements of the NTPs, and the level of compatibility between multiple NTPs per discharge summary prepared by different health professionals. Descriptive statistics were used to assess the number of NTPs, the presence of key elements, and the degree of compatibility between NTPs for the same patient. RESULTS A total of 100 discharge summaries of tube-fed patients admitted to a rehabilitation hospital during 2015-2017 were identified. The majority (91%) of discharge summaries included at least one NTP; 57 included more than one. Variance in the presence of key elements was observed in 165 NTPs prepared by physicians, nurses, and dietitians. Water amount and nutrition route were least reported by dietitians (6.3% and 9.4%, respectively), compared with physicians (77.6% and 81%) and nurses (77.3% and 62.7%). However, nutrition details were reported more frequently by dietitians (65.6%) than physicians (20.7%) and nurses (32%). Low compatibility was observed between dietitians and both nurses and physicians, in the range of 0%-26%. CONCLUSION Large discrepancies were found between NTPs for the same patient prepared by dietitians, physicians, and/or nurses, and a portion of patients arrived without any NTP.
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Affiliation(s)
- Pnina Marom
- Reuth Rehabilitation Hospital, Tel Aviv, Israel.,Department of Health Promotion, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hana'a Rayyan-Assi
- Reuth Rehabilitation Hospital, Tel Aviv, Israel.,Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | | | | | | | - Dov Albukrek
- Management Sector, Rabin Medical Center, Petah Tikva, Israel
| | - Rachel Dankner
- Reuth Rehabilitation Hospital, Tel Aviv, Israel.,Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Unit for Cardiovascular Epidemiology, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center Tel Hashomer, Ramat Gan, Israel
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[Malnutrition management of hospitalized patients with diabetes/hyperglycemia and concurrent pathologies]. NUTR HOSP 2022; 39:1-8. [PMID: 36546334 DOI: 10.20960/nh.04505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Introduction Type 2 diabetes mellitus is a highly prevalent disease worldwide, generating an increasing clinical and economic burden due to its micro- and macrovascular complications. Frequently, people with diabetes are hospitalized for various pathologies. These patients generally have higher risk of complications, prolonged hospitalizations and mortality. An additional factor that worsens the prognosis in these patients is the concurrence of malnutrition, especially in elderly people. All this makes the management of these patients challenging and requires a specific nutritional approach, whose purpose is to cover the nutritional requirements while always maintaining glycemic control. The purpose of this work is to provide, based on the evidence available in the literature and clinical experience, consensus recommendations by eighteen experts in Endocrinology and Nutrition on the nutritional approach of hospitalized patients with diabetes/ hyperglycemia and compare the optimal management, based on these recommendations with bedside usual care according to a panel of Spanish doctors surveyed about their daily clinical practice. This first article of this extraordinary issue of the journal Nutrición Hospitalaria describes the methodology of the study and the results obtained regarding common issues for all pathologies.
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Muacevic A, Adler JR, Kahlam A, Shaikh A, Ahlawat S. Trends Regarding Racial Disparities Among Malnourished Patients With Percutaneous Endoscopic Gastrostomy (PEG) Tubes. Cureus 2022; 14:e31781. [PMID: 36569690 PMCID: PMC9774994 DOI: 10.7759/cureus.31781] [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] [Accepted: 11/22/2022] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Percutaneous endoscopic gastrostomy (PEG) is performed in patients who cannot tolerate oral intake and who may require more than 30 days of nutritional support. These patients are at high risk for malnutrition, which itself can contribute to worsening clinical status. Racial disparities regarding access to sources of nutrition have been established. We aim to determine if such racial disparities regarding the diagnosis of malnutrition exist in this high-risk population. METHODS The National Inpatient Sample (NIS) was queried for patients with International Classification of Diseases, Ninth Revision (ICD-9) diagnoses coding for PEG tube placement with or without a diagnosis of malnutrition. Results were stratified by race. Rates of PEG tube complications were assessed. Categorical and continuous data were assessed via chi-squared and analysis of variance (ANOVA) tests respectively. Binary and multiple logistic regression was used to control for confounders. RESULTS Black patients had the highest rates of malnutrition diagnoses, mechanical complications from gastrostomy placement, and the lowest rates of palliative care discussions. Asian or Pacific Islander patients had the highest rates of aspiration pneumonia, gastrointestinal bleeding, the greatest mortality rates, and the longest hospital stays. DISCUSSION Racial minorities had worse outcomes while Caucasians had shorter hospital stays and lower complication rates. Such disparities can be multifactorial in etiology, with lack of nutritional access, poor doctor-patient communication, and differential rates of insurance coverage contributing to poorer outcomes among racial minorities. More change is required to promote equity when managing patients with end-of-life diseases necessitating methods of nutritional support.
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Parr H, Sanders DS. Cui bono? PEG feeding. Clin Med (Lond) 2021; 21:e2-e4. [PMID: 33479075 DOI: 10.7861/clinmed.2020-0759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Percutaneous endoscopic gastrostomy (PEG) provides long-term nutritional support to those unable to tolerate intake orally. The benefits of a PEG depend on the indication and the individual, and are considered when it has the potential to improve mortality, nutritional status or quality of life. Often, family members and healthcare professionals have to act on behalf of the patient. It is difficult for their personal values and emotions to not be a factor when deciding if to proceed with a PEG. This may result in unnecessary PEG placement. For certain indications (dementia for example), there is limited evidence of any benefits a PEG may give and may actually cause harm. Guidance to improve patient selection and increase education for healthcare professionals is essential in achieving the best outcome for the patient.
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Arvanitakis M, Gkolfakis P, Despott EJ, Ballarin A, Beyna T, Boeykens K, Elbe P, Gisbertz I, Hoyois A, Mosteanu O, Sanders DS, Schmidt PT, Schneider SM, van Hooft JE. Endoscopic management of enteral tubes in adult patients - Part 1: Definitions and indications. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:81-92. [PMID: 33260229 DOI: 10.1055/a-1303-7449] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ESGE recommends considering the following indications for enteral tube insertion: (i) clinical conditions that make oral intake impossible (neurological conditions, obstructive causes); (ii) acute and/or chronic diseases that result in a catabolic state where oral intake becomes insufficient; and (iii) chronic small-bowel obstruction requiring a decompression gastrostomy.Strong recommendation, low quality evidence.ESGE recommends the use of temporary feeding tubes placed through a natural orifice (either nostril) in patients expected to require enteral nutrition (EN) for less than 4 weeks. If it is anticipated that EN will be required for more than 4 weeks, percutaneous access should be considered, depending on the clinical setting.Strong recommendation, low quality evidence.ESGE recommends the gastric route as the primary option in patients in need of EN support. Only in patients with altered/unfavorable gastric anatomy (e. g. after previous surgery), impaired gastric emptying, intolerance to gastric feeding, or with a high risk of aspiration, should the jejunal route be chosen.Strong recommendation, moderate quality evidence.ESGE suggests that recent gastrointestinal (GI) bleeding due to peptic ulcer disease with risk of rebleeding should be considered to be a relative contraindication to percutaneous enteral access procedures, as should hemodynamic or respiratory instability.Weak recommendation, low quality evidence.ESGE suggests that the presence of ascites and ventriculoperitoneal shunts should be considered to be additional risk factors for infection and, therefore, further preventive precautions must be taken in these cases.Weak recommendation, low quality evidence.ESGE recommends that percutaneous tube placement (percutaneous endoscopic gastrostomy [PEG], percutaneous endoscopic gastrostomy with jejunal extension [PEG-J], or direct percutaneous endoscopic jejunostomy [D-PEJ]) should be considered to be a procedure with high hemorrhagic risk, and that in order to reduce this risk, specific guidelines for antiplatelet or anticoagulant use should be followed strictly.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with advanced dementia.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with a life expectancy shorter than 30 days.Strong recommendation, low quality evidence*.
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Affiliation(s)
- Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Edward J Despott
- Royal Free Unit for Endoscopy and Centre for Gastroenterology, UCL Institute for Liver and Digestive Health, The Royal Free Hospital, London, United Kingdom
| | - Asuncion Ballarin
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Torsten Beyna
- Department of Gastroenterology and Therapeutic Endoscopy, Evangelisches Krankenhaus Düsseldorf, Germany
| | - Kurt Boeykens
- Nutrition Support Team, AZ Nikolaas Hospital, Sint-Niklaas, Belgium
| | - Peter Elbe
- Department of Upper Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Ingrid Gisbertz
- Department of Gastroenterology, Bernhoven Hospital, Uden, The Netherlands
| | - Alice Hoyois
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Ofelia Mosteanu
- Department of Gastroenterology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital and University of Sheffield, United Kingdom
| | - Peter T Schmidt
- Department of Medicine (Solna), Karolinska Institutet, Stockholm, Sweden.,Department of Medicine, Ersta Hospital, Stockholm, Sweden
| | - Stéphane M Schneider
- Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, Gastroentérologie et Nutrition, Nice, France
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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Cui N, Zhao Y, Cao J. Clinical Features and Advantages of a Novel Percutaneous Endoscopic Gastrostomy Method. Med Sci Monit 2019; 25:9651-9657. [PMID: 31845650 PMCID: PMC6929529 DOI: 10.12659/msm.918507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background To study the clinical characteristics of novel percutaneous endoscopic gastrostomy. Material/Methods We retrospectively analyzed the hospital records of 173 patients undergoing various methods of gastrostomy (a novel PEG, traditional PEG, and surgical gastrostomy). Clinical characteristics were analyzed. For the novel PEG, the operation was as same as the traditional method for initial steps until the annular guide wire was inserted. The following steps were different: water was injected through an injection port to expand the capsule, then the water sac was confirmed to be close to the gastric wall under endoscope, and, finally, the incision was sutured and covered. Results Patient ages ranged from 42 to 93 years (60.8±9.2 years, 91 males and 82 females). Among all patients, there were 27 cases of brain trauma, 42 cases of cerebral infarction, 74 cases of esophageal or cardiac carcinoma, 21 cases of laryngocarcinoma, and 9 cases of Alzheimer disease. Clinical features were significantly better for novel PEG compared to traditional PEG: duration of operation (19.75±3.14 min vs. 37.86±5.33 min and 54.12±9.48 min, P<0.001), intraoperative blood loss (27.14±3.63 ml vs. 43.53±6.24 ml and 75.78±12.41 ml, P<0.001), postoperative pain score (1.12±0.19 pts vs. 3.85±0.44 pts and 6.22±1.06 pts; P<0.001), infection rate (1.35% vs. 3.77% and 2.17%, P<0.001), length of hospital stay (3.16±0.42 d vs. 5.68±0.78 d and 8.29±1.31 d, P<0.001), and time to free activity (2.24±0.26h vs. 3.74±0.48 h and 14.85±2.38 d, P<0.001). The incidence of complications such as wound infection (1.35% vs. 3.77% and 4.76%), vomiting (1.35% vs. 5.66% and 6.52%), and nausea (2.70% vs. 1.88% and 6.52%) in the novel PEG group was lower than in the other groups (P<0.0001). Improved outcomes were obtained without increased medical costs in the novel PEG group. Conclusions For patients with difficult postoperative oral nutrition, the novel PEG treatment resulted in overall better clinical outcomes than traditional PEG.
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Affiliation(s)
- Ning Cui
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Yu Zhao
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Jiwang Cao
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
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Lennard C. Best interest versus advance decisions to refuse treatment in advance care planning for neurodegenerative illness. ACTA ACUST UNITED AC 2019; 27:1261-1267. [PMID: 30457382 DOI: 10.12968/bjon.2018.27.21.1261] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article describes the role of nurses assisting people with degenerative illness in advance care planning (ACP) for a time when they may lose decision-making capacity. It looks at the concept of advance decisions to refuse treatment (ADRT), as defined in the Mental Capacity Act 2005 , exploring the legal, ethical and philosophical ramifications of carrying out, or overriding, formerly expressed wishes of someone who has subsequently lost decision-making capacity. It uses an illustrative composite case study of an individual with Huntington's disease whose prognosis includes future deterioration in swallowing, together with consideration of whether to have or refuse a percutaneous endoscopic gastrostomy. The author, who as part of his role cares for people with neurodegenerative conditions, including Huntington's disease, discusses the difficulties and dilemmas that nurses experience with ADRTs, drawing on personal experience. He suggests that, rather than focusing on ADRTs, ACP may be most effective in preparing people and their surrogates to make real-time decisions, based on a shared understanding of the individual's values.
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Affiliation(s)
- Chris Lennard
- Registered mental health nurse, Pirton Grange Specialist Care Centre, Pirton, Worcestershire
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Gallagher AM. Why nurture and support early career nutrition scientists-why not?! NUTR BULL 2018. [DOI: 10.1111/nbu.12352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Alison M. Gallagher
- Nutrition Innovation Centre for Food and Health (NICHE); Biomedical Sciences Research Institute; Ulster University; Coleraine Northern Ireland
- President/Chair, European Nutrition Leadership Platform (ENLP)
- Co-Chair, FENS2019 Science Committee
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