Original Article
Prevalence and factors associated with malnutrition in hospitalized patients with proximal femur fracture: Experience at Hospital Universitari Mutua Terrassa
Prevalencia y factores asociados a la desnutrición en pacientes ingresados con fractura proximal de fémur en el Hospital Universitario Mútua de Terrassa
Verónica Gil-Romeroa, Laura Puertas-Molinab,
, Núria Lleixà-Méndezc, Montserrat Ibarra-Rubioc
Corresponding author
a Unidad Funcional Interdisciplinaria Sociosanitaria, Hospital Universitario Mútua de Terrassa, Terrassa, Barcelona, Spain
b Unidad de Traumatología Geriátrica, Hospital Universitario Mútua de Terrassa, Terrassa, Barcelona, Spain
c Servicio de Nutrición y Dietética, Hospital Universitario Mútua de Terrassa, Terrassa, Barcelona, Spain
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In addition, suboptimal nutritional status both at the time of fracture and in the perioperative period has been associated with poorer functional recovery, longer hospital stays, increased postoperative complications and increased mortality in these patients.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In this regard, it appears that the prevention of malnutrition and early nutritional intervention may improve the recovery of patients with femoral fracture.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–6</span></a> Approximately half the patients admitted with proximal femur fracture are malnourished or at risk of malnutrition.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Different measures are used in nutritional assessment such as: nutritional screening tools, anthropometric parameters, functional assessment and biochemical values. Nutritional screening tools are agreed and accepted among the scientific societies as a useful method for the early detection of malnutrition or risk of malnutrition; the MNA<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> is postulated as a specific screening tool with high sensitivity for hospitalised geriatric patients.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In patients at risk of malnutrition, nutritional intervention with specific supplements helps optimise their nutritional status and, therefore, reduce postoperative complications.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">It is very important, therefore, to assess the nutritional status of these patients on admission to deliver treatment adjusted to needs detected, which will help us improve the outcomes of patients with femur fractures.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Objectives</span><p id="par0050" class="elsevierStylePara elsevierViewall">To assess the prevalence of malnutrition or risk of malnutrition in patients over 65 years of age admitted to the HUMT for a proximal femur fracture.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Specific objectives:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">To identify factors associated with the risk of malnutrition or malnutrition.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">To compare the hospital stay of patients according to degree of malnutrition.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0070" class="elsevierStylePara elsevierViewall">To compare patient mortality according to the degree of malnutrition.</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Method</span><p id="par0075" class="elsevierStylePara elsevierViewall">Retrospective observational study conducted in the HUMT from January 2016 to December 2019. The inclusion criteria for the study were patients over 65 years of age admitted for proximal femur fracture with full nutritional screening.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Patients who did not meet the inclusion criteria were excluded, and those who presented bilateral femur fractures.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The variables analysed were demographic, Mini Nutritional Assessment (MNA) test results, analytical parameters, patient provenance, functional capacity, cognitive status, hospital stay, and mortality.</p><p id="par0090" class="elsevierStylePara elsevierViewall">We performed a descriptive statistical (percentages, medians, and standard deviation according to type of variable) and a comparative analysis (Student’s t-test and chi<span class="elsevierStyleSup">2</span> test) using the EPIDAT 3.1 programme).</p><p id="par0095" class="elsevierStylePara elsevierViewall">According to our centre’s protocol, the usual procedure for a patient who arrives at the emergency department and is diagnosed with a femur fracture includes blood sampling to determine albumin values (g/dL) and lymphocyte count (mm<span class="elsevierStyleSup">3</span>).</p><p id="par0100" class="elsevierStylePara elsevierViewall">Once the patient is admitted to the hospital ward, during the first 24−48 h following admission, the case manager nurse or geriatric nurse performs nutritional screening using the first part of the MNA test that consists of 6 sections measuring dietary (decreased intake), anthropometric (weight loss, weight, size, BMI), and general assessment. The maximum score of the test is 14. If the patient’s cognitive status allows, the patient is asked the questions and, if not, the family member or relevant caregiver.</p><p id="par0105" class="elsevierStylePara elsevierViewall">In those patients whose MNA screening result indicates malnutrition (MNA ≤ 7) or risk of malnutrition (MNA = 8–11), the rest of the MNA assessment is performed, which includes anthropometric measurements (in cm) of the calf circumference of the non-fractured limb and the brachial circumference on the same side using a flexible tape. The patient is also referred to the nutrition and dietetics department. New blood samples are taken to determine prealbumin (mg/dl) and transferrin (mg/dl) levels).</p><p id="par0110" class="elsevierStylePara elsevierViewall">The patients’ functional capacity prior to the fracture is assessed by the Interdisciplinary Functional Unit team using the Barthel scale and cognitive status is evaluated with the Pfeiffer test.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The hospital dietician-nutritionist, once the referral report has been received and within the next 24−48 h, continues with the MNA assessment, which consists of 18 questions and goes into more specific aspects of the diet. The maximum MNA score is 30 and classifies individuals as follows: normally nourished (≥24 points), at risk of malnutrition (between 23.5 and 17 points), and malnourished (<17 points).</p><p id="par0120" class="elsevierStylePara elsevierViewall">After performing the final assessment, the dietician-nutritionist assesses the most appropriate nutritional intervention that should take place during the patient’s hospital stay, which may include adaptation of the diet, calorie, and protein enrichment of the diet, and/or the use of nutritional supplements.</p><p id="par0125" class="elsevierStylePara elsevierViewall">The patient’s adherence to the dietary or nutritional supplementation regimen during their hospital stay is then assessed and modifications made if deemed appropriate.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Days prior to discharge, the nurse manager or geriatric nurse and the dietician-nutritionist assess the best nutritional treatment for the patient when discharged. If the patient needs to continue taking nutritional supplements, the family is given a prescription for the next 30 days, which is dispensed by the hospital pharmacy service. The patient and family are also given the document “Dietary advice and strategies to enrich the diet” and it is explained to them.</p><p id="par0135" class="elsevierStylePara elsevierViewall">The data are collected in the patient’s computerised clinical history, through a form created to collect these data, and in a database of the orthopaedic surgery and traumatology department.</p><p id="par0140" class="elsevierStylePara elsevierViewall">The major limitation of the study is the loss of patients who are not screened during their hospital stay for organisational reasons on public holidays and/or holiday periods of the nurses in charge.</p><p id="par0145" class="elsevierStylePara elsevierViewall">The study was assessed and approved by the HUMT ethics committee in January 2021. Informed consent was not requested as this is standard care practice in all patients admitted with femur fractures. The researchers of the study undertake to safeguard and make effective use of the data collected, respecting the principles of confidentiality.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0150" class="elsevierStylePara elsevierViewall">The study population was 698 patients, as 68 patients who were not screened during their hospital stay were excluded. The mean age was 84.3 years (SD 7.4), of which 523 (75%) were women (p < 0.001).</p><p id="par0155" class="elsevierStylePara elsevierViewall">The prevalence of malnutrition in the study population was 39.4% (275). Of the patients, 31.5% (220) had an MNA score indicating a risk for malnutrition (MNA = 17–23.5) and 7.9% (55) indicating malnutrition (MNA < 17).</p><p id="par0160" class="elsevierStylePara elsevierViewall">The mean albumin value for malnourished patients was 3 (SD 0.4) and 3.7 (SD 0.5) for patients at risk of malnutrition. Prealbumin was 11.8 (SD 2.9) in malnourished patients and 12.3 (SD 4.5) in patients at risk of malnutrition.</p><p id="par0165" class="elsevierStylePara elsevierViewall">A total of 77 patients (28%) who came from residential care presented malnutrition or nutritional risk and a total of 65 (15.4%) had an adequate nutritional status (p < 0.003). A total of 198 (72%) of the patients who came from home were malnourished or at risk and 358 (84.6%) well nourished (p < 0.001).</p><p id="par0170" class="elsevierStylePara elsevierViewall">Of the patients with moderate-total dependency, according to the Barthel index, a total of 121 patients (48.7%) were malnourished or at risk of malnutrition and 61 (14.4%) well nourished (p < 0.001). <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the detailed results according to the patients’ degree of dependency.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">According to the Pfeiffer test, 154 (56%) of the malnourished patients or those at risk of malnutrition and 122 (28.8%) of the normally nourished patients had mild to severe cognitive impairment (p < 0.001). The results obtained with the Pfeiffer test according to the patients’ degree of cognitive impairment are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">The mean length of stay of the patients who were well nourished was 11.3 days and that of those at risk of malnutrition or malnourished was 12.2 days (p = 0.034).</p><p id="par0185" class="elsevierStylePara elsevierViewall">The results obtained in terms of in-hospital mortality, at one month and at three months after the fracture show statistical significance according to the patients’ degree of malnutrition (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0190" class="elsevierStylePara elsevierViewall">Our study shows a high prevalence of nutritional risk in patients over 65 years of age admitted for proximal femur fracture. The figures obtained in our study are similar to those described in other studies with similar characteristics in terms of demographic data and prevalence of malnutrition.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> These results are possibly related to functional dependence and cognitive impairment levels, since, in effect, patients with greater functional dependence have a higher prevalence of malnutrition and these results coincide with those obtained in similar studies.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–6,10</span></a> The presence of cognitive impairment in the patients studied is statistically significant in those with malnutrition. However, it was not possible to compare these data as the studies reviewed do not compare cognitive impairment with malnutrition in this group of patients.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">The hospital stay observed in our study of malnourished patients is not statistically significant when compared with the data described in malnourished patients admitted for other conditions.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13</span></a> However, according to the results obtained, the malnourished patients or those at risk of malnutrition required at least one more day of hospital stay.</p><p id="par0200" class="elsevierStylePara elsevierViewall">Mortality both in hospital and at one and three months after the fracture is clearly higher in malnourished patients, and is statistically significantly higher than in patients with adequate nutritional status, coinciding with the results obtained in the work of Jódar et al. and Malafarina.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">The results obtained demonstrate the importance of systematic nutritional screening in this population group for the early detection of patients at risk of malnutrition.</p><p id="par0210" class="elsevierStylePara elsevierViewall">In subsequent studies it would be interesting to include the assessment of the patients studied once they have been discharged from hospital to determine the efficacy of nutritional intervention.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interests</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1750044" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1541506" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1750045" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1541507" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Objectives" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Method" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-03-02" "fechaAceptado" => "2021-11-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1541506" "palabras" => array:4 [ 0 => "Hip fracture" 1 => "Elderly" 2 => "Malnutrition" 3 => "Mini Nutritional Assessment" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1541507" "palabras" => array:4 [ 0 => "Fractura fémur" 1 => "Ancianos" 2 => "Desnutrición" 3 => "Mini Nutritional Assessment" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Malnutrition is commonly associated with elderly patients with femoral fractures. Approximately 50% of hospitalized patients with a femoral fracture are malnourished or at risk of malnourishment. This situation may have a negative impact on outcomes and results for these patients. Malnourishment has been associated with an increased risk of complications, mortality, poor recovery, and delayed length of stay.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A retrospective observational study was conducted at our institution to evaluate the prevalence of malnutrition or risk of malnourishment in 766 hospitalized patients from January 2016 to December 2019. Furthermore, we identified factors that are associated with malnutrition. We also compared length of stay and mortality according to the degree of malnutrition.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The mean age for patients included was 84.6 years and 75% of patients were female. The Mini Nutritional Assessment test results showed 7.9% of patients were malnourished and 31.5% at risk of malnourishment.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Our study results indicate a high prevalence of malnutrition and risk of malnourishment in hospitalized elderly patients with a femoral fracture.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La desnutrición es uno de los factores asociados a la fractura de fémur en pacientes ancianos. Aproximadamente, la mitad de los pacientes ingresados con una fractura de fémur están desnutridos o en situación de riesgo nutricional. Esto puede influir de forma negativa en la evolución de estos pacientes, ya que la desnutrición se asocia a un aumento del riesgo de complicaciones, mayor mortalidad, peor recuperación funcional y estancias hospitalarias más largas.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Método</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Se ha realizado un estudio observacional retrospectivo con el objetivo de evaluar la prevalencia de desnutrición o riesgo nutricional de los 766 pacientes que ingresaron en el Hospital Universitario Mútua de Terrassa con fractura de fémur entre enero de 2016 y diciembre de 2019. También se han identificado los factores que podrían estar asociados a la desnutrición y se han comparado aspectos como estancia hospitalaria y mortalidad de los pacientes según el grado de desnutrición.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La edad media de los pacientes es de 84,6 años y el 75% son mujeres. Los resultados del test Mini Nutritional Assessment muestran que el 7,9% de los pacientes están desnutridos y el 31,5% presenta una situación de riesgo nutricional.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Nuestro estudio muestra una elevada prevalencia de desnutrición o de situación de riesgo nutricional en pacientes ingresados con fractura proximal de fémur.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Gil-Romero V, Puertas-Molina L, Lleixà-Méndez N, Ibarra-Rubio M. Prevalencia y factores asociados a la desnutrición en pacientes ingresados con fractura proximal de fémur en el Hospital Universitario Mútua de Terrassa. Enferm Clin. 2022;32:234–238.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Functional dependency/nutritional status \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total (n = 698) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Normally nourished (n = 423) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Malnourished or at risk (n = 275) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total dependency (<20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 (2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 (4.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Severe dependency (20–35) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70 (10%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 (4.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">49 (17.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate dependence (40–55) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">111 (15.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38 (8.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">73 (26.5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mild dependency (60–95) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">330 (47.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">212 (50.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">118 (42.9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Independent (100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">166 (23.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">143 (33.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 (8.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Not recorded \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (1.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Functional dependency (Barthel scale) and nutritional status (Mini Nutritional Assessment).</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cognitive impairment/nutritional status \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total (n = 698) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Normally nourished (n = 423) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Malnourished or at risk (n = 275) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No impairment (0–2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">351 (50.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">266 (62.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85 (30.9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mild impairment (3–4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">105 (15.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62 (14.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43 (15.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate impairment (5–7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85 (12.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35 (8.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 (18.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Severe impairment (8–10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">86 (12.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 (5.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 (22.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No record \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">71 (10.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35 (8.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36 (13.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Cognitive impairment (Pfeiffer’s test) and nutritional status (Mini Nutritional Assessment).</p>" ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mortality/nutritional status \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Normally nourished (n = 423) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Malnourished or at risk (n = 275) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (0.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.0021 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 month post fracture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (0.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 (3.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p < 0.013 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 months post fracture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (0.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 (7.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p < 0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Mortality and nutritional status (Mini Nutritional Assessment).</p>" ] ] 3 => array:5 [ "identificador" => "tb0005" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec9005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect9065">What is known?</span><p id="par0015" class="elsevierStylePara elsevierViewall">Proximal femur fracture is the most significant of the osteoporotic fractures. The number of cases is expected to increase each year due to the increasingly ageing population. Malnutrition is one of the risk factors associated with femur fracture in these patients.</p></span><span id="sec1010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect4070">What does this paper contribute?</span><p id="par0025" class="elsevierStylePara elsevierViewall">We aimed to determine the prevalence of malnutrition in patients admitted to the Hospital Universitari Mútua de Terrassa for femur facture and to see whether these results are like those of other published studies. We identify other factors that might be associated with malnutrition and compare certain variables according to the degree of malnutrition.</p></span></span>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiologia de las fractures osteoporóticas. Mortalidad y morbilidad" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E. Jódar" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Osteoporos Metab Miner" "fecha" => "2010" "volumen" => "4" "paginaInicial" => "5" "paginaFinal" => "9" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effects of nutritional status on 6-month outcome of hip fractures in elderly patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "K.Y.D. Miu" 1 => "P.S. Lam" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.5535/arm.2017.41.6.1005" "Revista" => array:5 [ "tituloSerie" => "Ann Rehabil Med" "fecha" => "2017" "volumen" => "41" "paginaInicial" => "1005" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29354577" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nutritional status and nutritional treatment are related to outcomes and mortality in older adults with hip fracture" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "V. Malafarina" 1 => "J. Reginster" 2 => "S. Cabrerizo" 3 => "O. Bruyère" 4 => "J. Kanis" 5 => "J.A. Martinez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Nutrients" "fecha" => "2018" "volumen" => "10" "paginaInicial" => "555" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nutrition screening tools: does one size fit all? A systematic review of screening tools for the hospital setting" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.A. van Bokhorst-de van der Schueren" 1 => "P.R. Guaitoli" 2 => "E.P. Jansma" 3 => "H.C. de Vet" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.clnu.2013.04.008" "Revista" => array:6 [ "tituloSerie" => "Clin Nutr" "fecha" => "2014" "volumen" => "33" "paginaInicial" => "39" "paginaFinal" => "58" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23688831" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pre-fracture nutritional status is predictive of functional status at discharge during the acute phase with hip fracture patients: a multicenter prospective cohort study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "T. Inoue" 1 => "S. Misu" 2 => "T. Tanaka" 3 => "S. Sakamoto" 4 => "K. Iwata" 5 => "Y. Chuman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.clnu.2016.08.021" "Revista" => array:7 [ "tituloSerie" => "Clin Nutr" "fecha" => "2017" "volumen" => "36" "paginaInicial" => "1320" "paginaFinal" => "1325" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27612921" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0168827811002078" "estado" => "S300" "issn" => "01688278" ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute phase nutritional screening tool associated with funcional outcomes of hip fracture patients: a longitudinal study to compare MNA-SF, MUST, NRS-2002 and GNRI" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "T. Inoue" 1 => "S. Misu" 2 => "T. Tanaka" 3 => "T. Kakehi" 4 => "R. Ono" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.clnu.2018.01.030" "Revista" => array:6 [ "tituloSerie" => "Clin Nutr" "fecha" => "2019" "volumen" => "38" "paginaInicial" => "220" "paginaFinal" => "226" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29456030" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Quick and easy is not without cost: implications of poorly performing nutrition sreening tools in hip fracture" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.J. Bell" 1 => "J.D. Bauer" 2 => "S. Capra" 3 => "R.C. 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