[Show abstract][Hide abstract] ABSTRACT: Background
Malnutrition is common amongst hospitalised older patients and associated with increased morbidity and mortality. Poor dietary intake results from factors including acute illness and cognitive impairment but additionally patients may have difficulty managing at mealtimes. Use of volunteers to help at mealtimes is rarely evaluated.Objectives
To obtain multiple perspectives on nutritional care of older inpatients, acceptability of trained volunteers and identify important elements of their assistance.DesignA qualitative study 1 year before and after introduction of volunteer mealtime assistants on one ward and parallel comparison with a control ward in a Medicine for Older People department at a UK university hospital.Participants and methodsSemi-structured interviews and focus groups, in baseline and intervention years, with purposively sampled nursing staff at different levels of seniority; patients or close relatives; and volunteers.ResultsAt baseline staff felt under pressure with insufficient people assisting at mealtimes. Introducing trained volunteers was perceived by staff and patients to improve quality of mealtime care by preparing patients for mealtimes, assisting patients who needed help, and releasing nursing time to assist dysphagic or drowsy patients. There was synergy with other initiatives, notably protected mealtimes. Interviews highlighted the perceived contribution of chronic poor appetite and changes in eating patterns to risk of malnutrition.Conclusions
Improved quality of mealtime care attributed to volunteers’ input has potential to enhance staff morale and patients’/relatives’ confidence. A volunteer mealtime assistance scheme may work best when introduced in context of other changes reflecting commitment to improving nutrition.Implications for practice(i) A mealtime assistance scheme should incorporate training, supervision and support for volunteers; (ii) Good relationships and a sense of teamwork can develop between wards staff and volunteers; (iii) Impact may be maximised in the context of ‘protected mealtimes’.
International Journal of Older People Nursing 08/2014;
[Show abstract][Hide abstract] ABSTRACT: Background: Recommendations effectively restrict the infusion duration of lipid-containing parenteral nutrition (PN) from a single bag, purportedly because it encourages growth of potential microbial contaminants more than lipid-free PN. Since other variables, including osmolarity, may independently affect microbial growth, this study examined variables affecting growth of Escherichia coli and Enterococcus durans in PN infusates. Materials and Methods: Growth of E coli and E durans was assessed in quadruplicate in 12 different PN infusates, with and without lipid, in varying glucose concentrations. Results: Results are presented as mean log10 colony-forming units (cfu)/mL ± SEM at 48 hours. The log10cfu/mL of both E coli and E durans in PN increased considerably after adjustment for baseline log10cfu/mL and pH, from 1.093 to 2.241 (P < .001) and from 0.843 to 3.451 (P < .001) respectively. Growth of each microorganism was independently increased by lipid inclusion, or increasing the proportion of nonnitrogen energy from lipid, and reduced by raising the glucose concentration or energy density. Increasing the osmolarity of lipid-PN with glucose or sodium chloride reduced growth but only significantly for sodium chloride (E coli, P = .025; E durans, P = .045). Induced changes in pH affected the growth of the 2 organisms differently. Conclusion: The presence of lipid and an increasing proportion of energy from lipid in PN favored the growth of E coli and E durans. Osmolarity changes and the nutrient type causing these changes independently affect the growth of these microbes. Each effect needs to be considered when establishing guidelines based on the growth of potential contaminants in different types of PN.
JPEN. Journal of parenteral and enteral nutrition. 06/2014;
[Show abstract][Hide abstract] ABSTRACT: There is controversy about the indications for home parenteral nutrition (HPN) during the palliative phase of malignancy causing inoperable gastrointestinal obstruction (IBO). This is partly due to uncertainty about the survival of patients. This study aimed to establish the survival characteristics of these patients in order to inform decisions about the use of HPN.
Gut 06/2014; 63(Suppl 1):A12-A13. · 10.73 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine the feasibility and acceptability of using trained volunteers as mealtime assistants for older hospital inpatients.
Poor nutrition among hospitalised older patients is common in many countries and associated with poor outcomes. Competing time pressures on nursing staff may make it difficult to prioritise mealtime assistance especially on wards where many patients need help.
Mixed methods evaluation of the introduction of trained volunteer mealtime assistants on an acute female medicine for older people ward in a teaching hospital in England.
A training programme was developed for volunteers who assisted female inpatients aged 70 years and over on weekday lunchtimes. The feasibility of using volunteers was determined by the proportion recruited, trained, and their activity and retention over one year. The acceptability of the training and of the volunteers' role was obtained through interviews and focus groups with 12 volunteers, nine patients and 17 nursing staff.
Fifty-nine potential volunteers were identified: 38 attended a training session, of whom 29 delivered mealtime assistance, including feeding, to 3911 (76%) ward patients during the year (mean duration of assistance 5·5 months). The volunteers were positive about the practical aspects of training and ongoing support provided. They were highly valued by patients and ward staff and have continued to volunteer.
Volunteers can be recruited and trained to help acutely unwell older female inpatients at mealtimes, including feeding. This assistance is sustainable and is valued.
This paper describes a successful method for recruitment, training and retention of volunteer mealtime assistants. It includes a profile of those volunteers who provided the most assistance, details of the training programme and role of the volunteers and could be replicated by nursing staff in other healthcare units.
Journal of Clinical Nursing 03/2014; · 1.32 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:Mosttechniquesformeasuringbodycompositionare basedon2-componentmodels(2-CMs)anddependonassumptions relating to the constancy of the density (DFFM) and hydration frac- tion (HFFFM) of fat-free mass (FFM). Objectives: The objectives were to determine whether these as- sumptions are systematically violated in patients with cirrhosis and to assess the validity of the estimates of body composition obtained in these patients by using 2-CM techniques. Design: Body composition was assessed by using a 4-component model (4-CM), which was based on data obtained from densitome- try,deuteriumdilution,anddual-energyX-rayabsorptiometry,in20 patients with cirrhosis who had no evidence of fluid retention and in 20pair-matchedhealthycontrolsubjects.Theresultswerecompared with those obtained by using "reference" and "bedside" 2-CM tech- niques. Results: The mean (SD) DFFM was significantly lower in the patientswithcirrhosis(1.0910.008comparedwith1.1000.006 kg/L; P 0.001); no significant difference in HFFFM was observed betweenthepatientsandcontrolsubjects(74.52.6comparedwith 73.5 2.1), although there was greater variability in the patients. Significantdifferenceswereobservedinthebody-compositionvari- ables obtained by using the "reference" 2-CM techniques compared with the 4-CM—the 95% limits of agreement in the patients with cirrhosis exceeded 5% body fat and 3 kg FFM; the corresponding valuesforthe"bedside"2-CMtechniqueswere11%bodyfatand7.5 kg FFM. Conclusions: Assumptions relating to the constancy of the DFFM and HFFFM are violated in patients with cirrhosis. Thus, standard 2-CM techniques provide inaccurate body composition estimates in this patient population. Am J Clin Nutr 2006;84:1151-62.
[Show abstract][Hide abstract] ABSTRACT: The adverse effects of disease-related malnutrition (DRM) on health care use and costs are well substantiated. However, the impact of managing DRM with nutritional support on health care use, including hospital (re)admissions requires exploration. This systematic review (9 RCT, n=1190) examined the effects of oral nutritional supplements (ONS) on hospital (re)admissions. Meta-analysis of 6 RCT (n=852) with data on the proportion of patients (re)admitted to hospital showed significant reductions with ONS vs. routine care (OR 0.59, 95% CI 0.43 to 0.80, P=0.001), including 5 RCT (n=826) that recorded readmissions (OR 0.59, 95% CI 0.43 to 0.80), P=0.001). The significant reduction in (re)admissions was found in meta-analyses of ONS trials in various settings and in patients with DRM or of varied nutritional status. A larger meta-analysis (8 RCT, n=999) that combined other (re)admissions data using standardised differences also showed a significant reduction with ONS (effect size -0.23, 95% CI -0.36 to -0.10, P=0.001). Most of these trials (75%) were in older people aged ≥65 years (6 RCT, n=834, effect size -0.18, 95% CI -0.31 to -0.04, P=0.011). This systematic review shows that ONS significantly reduce hospital (re)admissions, particularly in older patient groups, with economic implications for health care.
Ageing research reviews 07/2013; · 5.62 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Because lipid putatively encourages contaminant growth it has been proposed that infusion of lipid-containing parenteral nutrition (PN) bags should be restricted to 24 h (48 h or longer if lipid free). This study aimed to examine this proposal by identifying factors affecting Candida albicans growth in PN.
C. albicans growth was assessed in quadruplicate in 12 PN infusates, with and without lipid and varying glucose concentrations.
The results are presented as mean ± SEM. Baseline log10 colony forming units (cfu)/mL (1.806 ± 0.015) increased substantially by 48 h in the PN infusates (to 3.731 ± 0.059). In PN infusates (pH 6.14 ± 0.01) growth was unaffected by the presence of 5% w/v lipid (0.246 ± 0.156 log10 cfu/mL decrease; P = 0.127), and independently suppressed by increasing glucose concentration (0.438 ± 0.174 log10 cfu/mL decrease per 10% increase in w/v glucose; P = 0.018). In a separate analysis growth was suppressed by increasing energy density (0.520 ± 0.179 log10 cfu/mL decrease per 1000 kcal non-nitrogen energy in 2 L; P = 0.007), without a significant effect of % non-nitrogen energy from lipid (0.056 ± 0.036 log10 cfu/ml increase per 10%; P = 0.082).
Using a framework developed to examine growth of potential contaminants in PN, the inclusion of lipid emulsion in PN produced no specific effect on the growth of C. albicans, other than by increasing energy density. Growth was independently suppressed by increasing either glucose concentration or non-nitrogen energy density.
[Show abstract][Hide abstract] ABSTRACT: Background: Handwritten recycled paper prescription for parenteral nutrition (PN) may become a concentrated source of viable contaminants, including pathogens. This study examined the effect of using fresh printouts of electronic prescriptions on these contaminants. Materials and Methods: Cellulose sponge stick swabs with neutralizing buffer were used to sample the surfaces of PN prescriptions (n = 32 handwritten recycled; n = 32 printed electronic) on arrival to the pharmacy or following printing and PN prescriptions and bags packaged together during delivery (n = 38 handwritten recycled; n = 34 printed electronic) on arrival to hospital wards. Different media plates and standard microbiological procedures identified the type and number of contaminants. RESULTS: Staphylococcus aureus, fungi, and mold were infrequent contaminants. Nonspecific aerobes more frequently contaminated handwritten recycled than printed electronic prescriptions (into pharmacy, 94% vs 44%, Fisher exact test P < .001; onto wards, 76% vs 50%, P = .028), with greater numbers of colony-forming units (CFU) (into pharmacy, median 130 [interquartile range (IQR), 65-260] vs 0 [0-75], Mann-Whitney U test, P < .001; onto wards, median 120 [15-320] vs 10 [0-40], P = .001). Packaging with handwritten recycled prescriptions led to more frequent nonspecific aerobic bag surface contamination (63% vs 41%, Fisher exact test P = .097), with greater numbers of CFU (median 40 [IQR, 0-80] vs 0 [0-40], Mann-Whitney U test, P = .036). Conclusion: The use of printed electronic PN prescriptions can reduce microbial loads for contamination of surfaces that compromises aseptic techniques.
Journal of Parenteral and Enteral Nutrition 03/2013; · 2.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Currently there is confusion about the value of using nutritional support to treat malnutrition and improve functional outcomes in chronic obstructive pulmonary disease (COPD). This systematic review and meta-analysis of randomised controlled trials (RCTs) aimed to clarify the effectiveness of nutritional support in improving functional outcomes in COPD. A systematic review identified 12 RCTs (n = 448) in stable COPD patients investigating the effects of nutritional support [dietary advice (1 RCT), oral nutritional supplements (ONS; 10 RCTs), enteral tube feeding (1 RCT)] versus control on functional outcomes. Meta-analysis of the changes induced by intervention found that whilst respiratory function (FEV(1,) lung capacity, blood gases) was unresponsive to nutritional support, both inspiratory and expiratory muscle strength (PI max +3.86 SE 1.89 cm H(2) O, P = 0.041; PE max +11.85 SE 5.54 cm H(2) O, P = 0.032) and handgrip strength (+1.35 SE 0.69 kg, P = 0.05) were significantly improved, and associated with weight gains of ≥ 2 kg. Nutritional support produced significant improvements in quality of life in some trials, although meta-analysis was not possible. It also led to improved exercise performance and enhancement of exercise rehabilitation programmes. This systematic review and meta-analysis demonstrates that nutritional support in COPD results in significant improvements in a number of clinically relevant functional outcomes, complementing a previous review showing improvements in nutritional intake and weight.
[Show abstract][Hide abstract] ABSTRACT: Aseptic techniques are required to manipulate central venous lines and prepare intravenous doses. This study aimed to examine whether different aseptic techniques affect the contamination rates of intravenous doses prepared on hospital wards. Syringes of tryptic soy broth test media prepared by one pharmacy operator and five nurses were assessed for contamination. The pharmacy operator achieved lower contamination than the nurses (0.0% vs 6.9%; Fisher's exact test, P < 0.001). Contamination differed significantly between nurses (∼2-17% of syringes; binary logistic regression, P = 0.018). In conclusion, appropriate training and experience in aseptic techniques should be embedded into routine clinical practice to reduce contamination rates.
The Journal of hospital infection 01/2013; · 3.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Malnutrition is common in older people in hospital and is associated with adverse clinical outcomes including increased mortality, morbidity and length of stay. This has raised concerns about the nutrition and diet of hospital in-patients. A number of factors may contribute to low dietary intakes in hospital, including acute illness and cognitive impairment among in-patients. The extent to which other factors influence intake such as a lack of help at mealtimes, for patients who require assistance with eating, is uncertain. This study aims to evaluate the effectiveness of using trained volunteer mealtime assistants to help patients on an acute medical ward for older people at mealtimes.Methods/designThe study design is quasi-experimental with a before (year one) and after (year two) comparison of patients on the intervention ward and parallel comparison with patients on a control ward in the same department. The intervention in the second year was the provision of trained volunteer mealtime assistance to patients in the intervention ward. There were three components of data collection that were repeated in both years on both wards. The first (primary) outcome was patients' dietary intake, collected as individual patient records and as ward-level balance data over 24 hour periods. The second was clinical outcome data assessed on admission and discharge from both wards, and 6 and 12 months after discharge. Finally qualitative data on the views and experience of patients, carers, staff and volunteers was collected through interviews and focus groups in both years to allow a mixed-method evaluation of the intervention. DISCUSSION: The study will describe the effect of provision of trained volunteer mealtime assistants on the dietary intake of older medical in-patients. The association between dietary intake and clinical outcomes including malnutrition risk, body composition, grip strength, length of hospital stay and mortality will also be determined. An important component of the study is the use of qualitative approaches to determine the views of patients, relatives, staff and volunteers on nutrition in hospital and the impact of mealtime assistance.Trial registrationTrial registered with ClinicalTrials.gov NCTO1647204.
[Show abstract][Hide abstract] ABSTRACT: Although nutritional screening with a tool such as the Malnutrition Universal Screening Tool (MUST) is recommended for outpatients, staff are under pressure to undertake a variety of other tasks. Little attention has been paid to the validity of patient self-screening with MUST.
This study in 205 outpatients with a mean (±SD) age of 55 ± 17 y (56% male) assessed the practicalities of self-screening, its agreement with screening undertaken by a trained health care professional (HCP), and its test-retest reliability.
After the participants provided consent, screening was undertaken by the patients themselves and then by a trained HCP who was unaware of the self-screening results. All patients completed an ease-of-use questionnaire. Test-retest reliability of self-screening was established in a subset of 60 patients.
A total of 19.6% of patients categorized themselves as "at risk" of malnutrition (9.8% medium, 9.8% high). For the 3-category classification of MUST (low, medium, high), agreement between self-screening and HCP screening was 90% (κ = 0.70; SE = 0.058, P < 0.001). For the 2-category classification (low risk, medium + high risk), agreement was 93% (κ = 0.78, SE = 0.057, P < 0.001). Disagreements were not systematically under- or overcategorized. Test-retest reliability was almost perfect (κ = 0.94, P < 0.001). Most patients (71%) completed self-screening in <5 min. Patients found the tool easy or very easy to understand (96%) and complete (98%), with 94% reporting that they were happy to screen themselves.
Self-screening involving MUST in outpatients is acceptable to patients, user-friendly, reliable, and associated with good agreement with HCP screening. This trial was registered at clinicaltrials.gov as NCT00714324.
American Journal of Clinical Nutrition 10/2012; 96(5):1000-7. · 6.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND & AIMS: Recommendations limit infusion of parenteral nutrition (PN) from bags with lipid to 24 h (48 h if lipid free) because lipid putatively encourages contaminant growth. This study aimed to examine these recommendations and identify factors affecting Staphylococcus epidermidis growth in PN. METHODS: S. epidermidis growth was assessed in quadruplicate in 12 PN regimens, with and without lipid and varying glucose concentrations. RESULTS: Baseline colony forming units (cfu)/mL (32.6) less than doubled at 48 h in all infusates. In PN infusates (pH 6.2 + 0.02 (SEM)) growth was independently increased by the presence of 5% w/v lipid (14.2 cfu/mL; P = 0.028), and glucose concentration (25.6 cfu/mL per 10% increase in w/v glucose; P = 0.003). In a separate analysis growth was stimulated by energy density (27.7 cfu/1000 kcal non-nitrogen energy in 2 L; P = 0.002), without a significant effect of % non-protein energy from lipid (-2.6 cfu/ml per 10%). CONCLUSIONS: Using a framework developed to examine growth of potential contaminants in PN, no evidence was found to support the specific recommendation to restrict the maximum infusion duration of lipid containing PN to a greater extent than lipid free PN. S. epidermidis growth was not only affected by the presence of lipid, but also glucose concentration and energy density.
[Show abstract][Hide abstract] ABSTRACT: The efficacy of nutritional support in the management of malnutrition in chronic obstructive pulmonary disease (COPD) is controversial. Previous meta-analyses, based on only cross-sectional analysis at the end of intervention trials, found no evidence of improved outcomes.
The objective was to conduct a meta-analysis of randomized controlled trials (RCTs) to clarify the efficacy of nutritional support in improving intake, anthropometric measures, and grip strength in stable COPD.
Literature databases were searched to identify RCTs comparing nutritional support with controls in stable COPD.
Thirteen RCTs (n = 439) of nutritional support [dietary advice (1 RCT), oral nutritional supplements (ONS; 11 RCTs), and enteral tube feeding (1 RCT)] with a control comparison were identified. An analysis of the changes induced by nutritional support and those obtained only at the end of the intervention showed significantly greater increases in mean total protein and energy intakes with nutritional support of 14.8 g and 236 kcal daily. Meta-analyses also showed greater mean (±SE) improvements in favor of nutritional support for body weight (1.94 ± 0.26 kg, P < 0.001; 11 studies, n = 308) and grip strength (5.3%, P < 0.050; 4 studies, n = 156), which was not shown by ANOVA at the end of the intervention, largely because of bias associated with baseline imbalance between groups.
This systematic review and meta-analysis showed that nutritional support, mainly in the form of ONS, improves total intake, anthropometric measures, and grip strength in COPD. These results contrast with the results of previous analyses that were based on only cross-sectional measures at the end of intervention trials.
American Journal of Clinical Nutrition 04/2012; 95(6):1385-95. · 6.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Controversies exist as to the suitability of various nutrition screening tools for various age groups, the incorporation of age and age-related criteria into some tools, and the procedures associated with tool selection.
Reviews of the literature and national and local datasets were used to identify the types of screening tools available for different age groups, the origins of age-related criteria, and the value of tool selection procedures based on predicting clinical outcomes.
Nutrition screening can be undertaken in fetuses, children, and adults over narrow or wide age ranges, for diagnostic or prognostic purposes, with or without nutritional interventions. Certain tools can establish malnutrition risk without using any nutritional criteria, whereas others can do so only with nutritional criteria. The incorporation of age and age-specific body mass index criteria into adult screening tools can influence the prevalence and age distribution of malnutrition, but no justification is usually provided for their use. In several circumstances, age alone can predict mortality and length of hospital stay much better than screening tools. We identified various methodologic problems in nutrition screening tool selection.
A comparison of nutrition screening tools designed for different age groups and different purposes can be problematic. Age and screening tools incorporating risk factors that are non-modifiable or generally weakly modifiable by nutritional support (e.g., age, disease severity) may predict outcomes of disease, but they are not necessarily suitable for predicting outcomes of nutritional support. To contextualize the findings, a framework for screening tool selection is suggested that takes into account a matrix of needs.
[Show abstract][Hide abstract] ABSTRACT: This study assessed the extent to which ulna length could be used to predict height and body mass index (BMI) in various groups of English and Portuguese hospitalised patients, and tidal volumes in critically ill patients at risk of requiring ventilatory support.
Bedside measurements of weight, height and ulna length were made in 507 patients (432 English, 75 Portuguese; 264 men, 243 women) with a mean age of 61.8±18.9 years, height 165.1±9.5 cm and BMI 26.7±5.43 kg/m(2).
Ulna length could be measured with ease in all subjects. The intra-observer technical error of measurement in the same subjects was 1%. Within each category of men and women aged <65 years and 65 years and over, there was no significant difference between the English and Portuguese in the intercept or regression coefficients for the ulna-height relationships. A strong relationship was found between predicted and measured height (r=0.963, standard error of the estimate 4.6 cm). The overall mean and s.d. of the difference was 0.3±2.7% of height, with no significant difference between English and Portuguese populations. The discrepancy between measured and predicted BMI corresponded to 0.7±5.5% (s.d.) (all subjects) and for ventilatory volumes predicted from height (critically ill subjects only) 0.7±7.1%.
Height can be predicted from ulna length with precision and ease in a wide range of patient groups, and without the need to use different equations in English and Portuguese populations. The predicted measurements are acceptable in most clinical circumstances.
European journal of clinical nutrition 02/2012; 66(2):209-15. · 3.07 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Oral nutritional supplements (ONS) play a key role in the management of malnutrition. This systematic review examined patients' compliance with ONS across healthcare settings and the influence of patient and ONS-related factors.
A systematic review identified 46 studies (n = 4328) of ONS in which data on compliance (% of prescribed quantity of ONS consumed) was available. Pooled mean %compliance was assessed overall and according to study design and healthcare setting. Inter-relationships between compliance and ONS-related and patient-related factors, and total energy intake were assessed.
Overall mean compliance with ONS was 78% (37%-100%; 67% hospital, 81% community; overall mean ONS intake 433 kcal/d). Percentage compliance was similar in randomised (79%) and non-randomised (77%) trials, with little variation between diagnostic groups. Compliance across a heterogeneous group of unmatched studies was positively associated with higher energy-density ONS and greater ONS and total energy intakes, negatively associated with age, and unrelated to amount or duration of ONS prescription.
This systematic review suggests that compliance to ONS is good, especially with higher energy-density ONS, resulting in improvements in patients' total energy intakes that have been linked with clinical benefits. Further research is required to address the compliance and effectiveness of other common methods of oral nutritional support.
[Show abstract][Hide abstract] ABSTRACT: Disease-related malnutrition is common, detrimentally affecting the patient and healthcare economy. Although use of high protein oral nutritional supplements (ONS) has been recommended to counteract the catabolic effects of disease and to facilitate recovery from illness, there is a lack of systematically obtained evidence to support these recommendations. This systematic review involving 36 randomised controlled trials (RCT) (n=3790) (mean age 74 years; 83% of trials in patients >65 years) and a series of meta-analyses of high protein ONS (>20% energy from protein) demonstrated a range of effects across settings and patient groups in favour of the high protein ONS group. These included reduced complications (odds ratio (OR) 0.68 (95%CI 0.55-0.83), p<0.001, 10 RCT, n=1830); reduced readmissions to hospital (OR 0.59 (95%CI 0.41-0.84), p=0.004, 2 RCT, n=546); improved grip strength (1.76 kg (95%CI 0.36-3.17), p<0.014, 4 RCT, n=219); increased intake of protein (p<0.001) and energy (p<0.001) with little reduction in normal food intake and improvements in weight (p<0.001). There was inadequate information to compare standard ONS (<20% energy from protein) with high protein ONS (>20% energy from protein). The systematic review and meta-analysis provides evidence that high protein supplements produce clinical benefits, with economic implications.
Ageing research reviews 12/2011; 11(2):278-96. · 5.62 Impact Factor