Intégration de lˈévaluation nutritionnelle à lˈexamen médicallors de lˈadmission à lˈhôpital

Protein-calorie malnutrition (PCM) negatively affects the healing process, morbidity and mortality as well as medical costs. The nutritional assessment at hospital admission is essential in order to determine the need for nutritional intervention and for optimizing it. Based on clinical evolution, the nutritional evaluation assesses the adequacy of energy intake to metabolic requirements, energy reserves and bodily functions. A global evaluation of nutritional status aims at defining whether the patient is well-nourished, moderately or severely malnourished and whether the causes of PCM will disappear, improve or worsen. A global nutritional evaluation should also define the healing potential in order to decide if the nutritional intervention should be immediate or delayed, maximal or partial. The diagnosis and quantification of PCM is based on several parameters determined by clinical, biochemical and functional tests. This review summarizes the clinically relevant methodologies and proposes a protocol for the nutritional evaluation of patients at hospital admission.     

Intérêts et limites des mesures de verticalité subjective pour l’évaluation des troubles de l’équilibre

The sense of verticality is considered one of the fundamental spatial parameters that the human being uses to establish mental images of the position of their body and the different parts of their body in space. It therefore plays a specific role in controlling posture. The perception of verticality results from the integration of visual, vestibular and somatosensory information. Different methods of verticality perception can be measured; the visual, haptic and postural vertical, each with different neurological integration circuits and thus the results can be separated into the different pathologies. Understanding the mechanisms which explain the changes in verticality perception, as well as their impact on balance, have been the focus of many studies over the last few years. In certain diseases, such as after a cerebral vascular accident (stroke), measurement of the perception of verticality is now part of the assessment of the balance issues seen in current clinical practice.     

Rôle du niveau verbal sur l’expression et l’évaluation de la douleur chez des sujets déficients intellectuels

Résumé Objectif  les études portant sur l’évaluation de la douleur chez les sujets déficients intellectuels concernent surtout la déficience profonde ou sévère. De fait, la littérature met en avant leur incapacité à utiliser les outils d’autoévaluation. Ce travail étudie l’expression verbale et l’évaluation de douleurs rapportées chez des sujets déficients intellectuels légers et moyens et le r?le du niveau verbal. Sujets et méthode  quatorze sujets atteints de déficience intellectuelle moyenne et légère, sans aucune atteinte physique agés de 8 à 18 ans (moyenne d’age 15 ans). A l’aide de l’EVA et de l’échelle des visages, ils ont évalué l’intensité douloureuse du personnage d’une vignette ou celle d’une douleur rapportée. Ils ont ensuite décrit ces douleurs. Résultats  les sujets déficients intellectuels de notre étude manifestent des capacités d’expression et d’évaluation de la douleur. Ils sont en mesure d’utiliser des outils d’autoévaluation pour estimer la douleur d’un personnage représenté sur une image ou bien une douleur rapportée. Conclusion  la présence de compétences à exprimer verbalement la douleur chez des sujets porteurs d’atteintes intellectuelles indique que ces compétences ne dépendent pas du niveau de développement de la pensée conceptuelle. Nous nous orientons désormais vers l’étude de la dynamique du dialogue entre le sujet et la personne chargée d’évaluer sa douleur.      

Réinsertion sociale et professionnelle du blessé de guerre militaire français. Expérience de la cohorte de blessés suivie entre 2004 et 2010 dans le service de médecine physique et de réadaptation de l’hôpital d’instruction des Armées Percy

From 2004, due to battle intensification, the French army has undergone an increasing violence in external operations, then wounded people had increased. Social and professional reintegration is still badly assessed. We have studied social and professional features, and quality of life of 49 French wounded soldiers hospitalized in physical medicine and rehabilitation in the military instruction hospital Percy, from 2004 to 2010. That study permitted to objectify the difficulties and could help to develop the ways to improve the reintegration. This is an early study, it should be interesting to assess the same patients after a longer follow-up.     

Utilisation de la sophrologie et de l’hypnose à l’hôpital: expérience d’une infirmière

Hypnosis, used by a nurse for painful procedure or to help the children upset with anxiety, is often a particularly adapted and effective response. Success requires an appropriate pharmacological synergy (nitrous oxide/oxygen mixture mostly). Besides the dissociation between sensory and emotional components of pain, these methods also offer a valuable relationship with the child. These methods also have their limit, and it is necessary to know how to regularly analyze the failures within the involved hospital teams.     

La T-cadhérine,troisième récepteur de l’adiponectine : structure et rôle en santé humaine

T-cadherin shows abundant expression in the cardiovascular system, in particular, in endothelial and smooth muscle cells. T-cadherin is a receptor for Hight Molecular Weight (HMW) and Medium Molecular Weight (MMW) isoforms of adiponectin, but due to the lack of transmembrane and cytoplasmic domains that are able to transmit the signal, T-cadherin rather acts as a co-receptor. T-cadherin is involved in remodeling of vascular walls and angiogenesis. In some models, T-cadherin plays critical roles in adiponectin-mediated revascularization and mediates the cardiac protective role of adiponectin. T-cadherin gene (CDH13) polymorphisms are strongly associated with adiponectin levels in genome wide association studies, and sometimes also with cardiometabolic risk. Our studies in the French population show associations between these polymorphisms and body mass index, type 2 diabetes, and nephropathy in subjects with type 1 diabetes. T-cadherin might have pleiotropic effects in human pathophysiology, both dependent and independent of plasma adiponectin levels.     

Rôle de l’enzyme 11β-hydroxystéroïde-déshydrogénase de type 1 dans le risque métabolique associé à l’obésité

Similarities between metabolic syndrome associated with abdominal obesity and Cushing syndrome led to the search of excessive local tissue exposition to glucocorticoids at the cellular levels, despite normal circulating plasma levels of cortisol. To this respect, 11β-hydroxysteroid-dehydrogenase type 1 (11HSD1), which converts cortisone (inactive) to cortisol (active) in target tissues, raises much interest. Both increased expression and activity of this enzyme has been reported in presence of obesity, at least in some tissues that play a major role in metabolic regulations, such as adipose tissue. Experimental data in rodents showed a direct link between increased 11HSD1 activity and the development of metabolic disturbances. Furthermore, studies in mice KO for 11HSD1 demonstrated the potential of the inhibition of this enzyme to alleviate the metabolic abnormalities related to diet-induced obesity. The administration of specific inhibitors of 11HSD1 resulted in significant improvement of glucose and lipid profiles, together with a weight reduction, provided that 11HSD1 activity was blocked in the adipose tissue (rather than in the liver). Preliminary observations when various, potent and selective, inhibitors of 11HSD1 given in humans also showed a diminution of insulin resistance, an improvement of glucose tolerance or glucose control and an amelioration of lipid profile. In case of confirmation of such promising results, selective inhibitors of 11HSD1 might represent a new pharmacological class aiming at treating metabolic abnormalities associated with obesity, including type 2 diabetes.     

Performance en réanimation médicale : le point de vue du directeur d’hôpital

The hospital director point of view about ICU performance is the best compromise between three criteria: quality of care delivered to each patient, economical performance, adequacy between the response of the hospital in a whole to the demand and need of the population. Each criteria includes results, process and structure indicators that should be specified for each ICU. A dialogue must be promoted between the ICU director and the hospital director in order to define priorities. The quality of such a dialogue is a performance per se.