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    Determinants of in-hospital muscle loss in acute ischemic stroke- Results of the Muscle Assessment in Stroke Study (MASS)
    (Churchill Livingstone, 2023) Gungor, Levent; Arsava, Ethem Murat; Guler, Ayse; Isikay, Canan Togay; Aykac, Ozlem; Caglayan, Hale Zeynep Batur; Kozak, Hasan Huseyin
    Background & aims: There is a change in the mass and composition of paretic and non-paretic skeletal muscles in the chronic phase of stroke. The multi-center, prospective, and observational Muscle Assessment in Stroke Study (MASS) was performed to evaluate the degree of muscle loss during the in-hospital acute stroke setting and determine factors contributing to this loss.Methods: Acute dysphagic ischemic stroke patients (n = 107) admitted to neuro-intensive care units were evaluated by computed tomography on days 1 and 14 after admission to determine the cross-sectional muscle area (CSMA) at the level of the mid-humerus, mid-thigh, and third lumbar vertebra. The percentage change in CSMA and variables associated with this change were evaluated by univariate and multivariate analyses.Results: There were significant reductions in CSMA in all the muscle groups analyzed; the most prom-inent change was observed in the arms (both: 14.2 +/- 10.7%; paretic: 17.7 +/- 11.6%; non-paretic: 10.1 +/- 12.5%), followed by the muscles in the legs (both: 12.4 +/- 8.7%; paretic: 12.9 +/- 9.9%; non-paretic: 12.0 +/- 9.3%) and L3-vertebra level (5.6 +/- 9.8%) (P < 0.001 for all). Higher calorie (r =-0.378, P < 0.001) or protein (r =-0.352, P < 0.001) intake was negatively associated with the decrease in CSMA of upper extremities. A substantial protein (>= 0.4 g/kg/d) or calorie (>= 5 kcal/kg/d) gap between targeted or actual intake was related to a larger decrease in CSMA in all the anatomic regions (P < 0.05 for all). Other significant predictors of muscle loss included history of diabetes mellitus, male sex, higher BMI, in-hospital infections, and the necessity for invasive mechanical ventilation.Conclusions: There is a considerable degree of loss in the global muscle mass in acute ischemic stroke patients over a two-week period. Along with several factors, falling significantly behind the daily protein or calorie targets was related to the decrease in the muscle area. Trial registration information: clinicaltrials.gov identifier NCT03825419.(c) 2023 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
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    Muscle mass as a modifier of stress response in acute ischemic stroke patients
    (Nature Portfolio, 2024) Arsava, Ethem Murat; Gungor, Levent; Sirin, Hadiye; Sorgun, Mine Hayriye; Aykac, Ozlem; Caglayan, Hale Zeynep Batur; Kozak, Hasan Huseyin
    Stroke triggers a systemic inflammatory response over the ensuing days after the cerebral insult. The age and comorbidities of the stroke population make them a vulnerable population for low muscle mass and sarcopenia, the latter being another clinical condition that is closely associated with inflammation, as shown by increased levels of pro-inflammatory biomarkers, including neutrophil-to-lymphocyte ratio (NLR). In this study, we evaluated the relationship between post-stroke NLR changes and muscle mass in a prospective cohort of acute ischemic stroke patients (n=102) enrolled in the Muscle Assessment in Stroke Study Turkey (MASS-TR). Admission lumbar computed tomography images were used to determine the cross-sectional muscle area of skeletal muscles at L3 vertebra level and calculate the skeletal muscle index (SMI). The median (IQR) SMI was 44.7 (39.1-52.5) cm(2)/m(2), and the NLR at admission and follow-up were 4.2 (3.0-10.5) and 9.4 (5.7-16.2), respectively. While there was no relationship between SMI and admission NLR, a significant inverse correlation was observed between SMI and follow-up NLR (r=-0.26; P=0.007). Lower SMI remained significantly associated (P=0.036) with higher follow-up NLR levels in multivariate analysis. Our findings highlight the importance of muscle mass as a novel factor related to the level of post-stroke stress response.
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    Nutritional Approach and Treatment in Patients with Stroke, An Expert Opinion for Turkey
    (Turkish Neurological Soc, 2018) Arsava, Ethem Murat; Aydogdu, Ibrahim; Gungor, Levent; Isikay, Canan Togay; Yaka, Erdem
    Cerebrovascular diseases comprise the most common category of inpatient cases taken care of by neurologists. Dysphagia and malnutrition are not rare after stroke. It is strongly recommended for neurologists to screen and treat swallowing disturbances and malnutrition in stroke patients. However, present scientific literature lacks clear evidence with regards to nutritional treatment strategies for stroke patients. This review and recommendation paper is written with the aim to standardize nutritional screening and treatment algorithms during acute and chronic phases of cerebrovascular diseases and guide neurologists in Turkey for their daily practice.
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    Optimal use of oral nutritional supplements (ONS) in medical nutrition therapy: ONS consensus report from KEPAN
    (Springernature, 2022) Bahat, Gulistan; Akmansu, Muge; Gungor, Levent; Halil, Meltem; Bicakli, Derya Hopanci; Koc, Nevra; Ozogul, Yusuf
    Medical nutrition therapy is one of the core components of the patient management, although its implication is still limited in daily practice globally. Clinicians are in need of guidance that will ease the application of medical nutrition therapy. The first treatment choice in medical nutrition therapy is the use of oral nutritional supplements (ONS) after or concomitant with dietary interventions. The pre and post-graduate curriculum for medical nutrition therapy is limited in most regions, worldwide. A report that is short, clear, and having clear-cut recommendations that will guide the primary healthcare professionals in indications, choice, practical application, follow-up, and stopping ONS would facilitate the application and success of medical nutrition therapy. KEPAN is the Clinical Enteral and Parenteral Nutrition Society of Turkey and is an active member of the European Society for Clinical Nutrition and Metabolism (ESPEN). In this study, we present the KEPAN ONS consensus report on optimal ONS use in medical nutrition therapy as outlined by works of academicians experienced in clinical application of ONS (eight working group academicians and 19 expert group academicians). This report provides 22 clear-cut recommendations in a question-answer format. We believe that this report could have a significant impact in the ideal use of ONS in the context of medical nutrition therapy when clinicians manage everyday patients.
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    Real World Data Estimation: Management and Cost-analysis of Stroke in Tertiary Hospitals in Turkey and the Impact of Co-morbid Malnutrition
    (Journal Neurological Sciences, 2016) Arsava, Ethem Murat; Ozcagli, Tahsin Gokcem; Berktas, Mehmet; Giray, Semih; Guler, Ayse; Gungor, Levent; Ozdemir, Ozcan; Uluc, Kayihan; Yaka, Erdem; Yesilot, Nilufer; Topcuoglu, Mehmet Akif; Seyhun, Oznur
    Objective: To evaluate the management and cost analysis of first-ever stroke patients in Turkey and determine the impact of comorbid malnutrition. Methods: This study was based on expert's view on the management and cost analysis of stroke patients with or without malnutrition via standardized questionnaire forms filled by experts according to their daily clinical practice. Cost items were related to medical treatment, healthcare resources utilization, tests, consultations and complications. Per admission and total annual direct medical costs were calculated with respect to co-morbid malnutrition. Results: Malnutrition was evident in 7.8(3.6)% [mean(standard error of mean; SEM)] of patients at admission; an additional 7.1(4.8)% and 0.9(0.6)% patients developed malnutrition during Neuro-ICU and stroke unit hospitalization, respectively. Length of hospital stay (LOS) was almost 2-fold in patients with malnutrition (P<0.01 for all hospital units). During the 1-year follow-up period a mean(SEM) of 93.8(15.4)% with and 43.3(3.7)% without malnutrition were expected to experience at least 1 complication. The mean (SEM) per patient annual cost of stroke was US$5201(740) in patients with malnutrition and US$3619(614) in patients without malnutrition, while the corresponding figures for per admission were US$3061(513) and US$1958(372), respectively. Conclusions: In conclusion, our findings revealed that management of stroke and its complications have a relatively high burden on the Turkish health reimbursement system. Furthermore, co-morbid malnutrition, being not uncommonly encountered, increased the overall costs and was associated with longer LOS and higher rate of expected complications during 1-year follow up.