Nutrition dans la période postopératoire (dont urgence)

Policies which tend to reduce surgical stress and therefore decrease catabolism and to improve anabolism could allow patients to recover more quickly and efficiently even after major surgery. In most instances, interruption of nutritional intake is not necessary after surgery. Oral intake can be started as soon as possible within the first 24 hours unless surgical contra-indication. Oral intake should be adjusted according to patient's tolerance. In patients without overt under-nutrition, postoperative nutritional support for periods of less than 7 days is not indicated. However, nutritional support is recommended when postoperative food intakes reach less than 60% of daily needs for 7 days. Moreover, early nutritional support should probably be administered if expected postoperative food intake will be less than 60% of daily needs for more than 7 days. In malnourished patients, nutritional support (using enteral rather than parenteral route) is strongly recommended within the first postoperative 24 hours regardless of preoperative nutritional support.     

Nutrition et prévention du déclin cognitif et démence

The potential effect of nutrition has become a topic of increasing scientific and public interest. In particular, there are arguments that nutrients (food and/or supplements) such as vitamins, trace minerals, lipids, can affect the risk of cognitive decline and dementia, especially in frail elderly people at risk of deficiencies. We reviewed in this paper data from prospective studies and randomised clinical trials (RCT) relating diet to risk of cognitive decline and dementia. We chose to focus our statements on homocysteine-related vitamins (B-vitamins), antioxidants nutrients (vitamins E and C, carotenoids, flavonoids, enzymatic cofactors) and dietary lipids. Results of the prospective studies are sometimes conflicting and stress the need to develop further prospective studies of adequate duration, including subjects whose diet is monitored at a sufficiently early stage or at least before the onset of disease or cognitive decline. The seemingly contradictory results between the observation studies and the RCT could be explained by the fact that the doses uses in clinical trials are much higher than the highest levels achieved by usual dietary intake which have been found to be associated with the lowest risk of cognitive decline in observational studies. More randomised clinical trials need to be conducted that focus on specific types of subjects (middle-aged and elderly populations; subjects with vitamins deficiencies, normal and high levels). Such research identifying the role of certain nutrients, certain foods or certain dietary behaviours, is an indispensable step before we can propose specific recommendations in the future.     

Nutrition et maladies neuromusculaires

Motorneurone diseases are caused by various alterations of motor unit. The most frequent associated nutritional trouble is malnutrition, but obesity can also occur. The aim of nutritional care, when possible integrated in a multidisciplinary team, is at least to maintain an optimal quality of life, and often to improve or permit the patient survival. Evaluation uses simple tools: dietetic investigation, measurement of weight and weight variation, calculation of body mass index. The first proposals are dietetic advices, adaptation of surroundings, and treatments of facial and dental dysmorphias, digestive diseases, salivary and psychological troubles. When these cares are insufficient, enteral nutrition is used, often through a gastrostomy tube. To debate with the patients and his close relations and to give informations are needed during all the follow-up.     

Place de la pharmaconutrition en périopératoire

Since 20 years, data from high quality studies have demonstrated that perioperative immunonutrition is able, even in well-nourished patients, to reduce septic complications, length of stay and costs, in elective digestive cancer surgery. Then update of recommendations for clinical practice has been proposed. As this treatment is effective, French system reimburses the cost of treatment since 2006. Educational programme is now necessary to diffuse state of art.     

Nutrition et accident vasculaire cérébral

Nutrition is an important factor to take into account in the management of stroke. Within the framework of primary and secondary prevention, different risk factors are now well known and designed as target, among them numerous nutritional factors like overweight or obesity, diabetes, dyslipidemia. At the opposite, stroke favours troubles of the glycoregulation and is a risk factor of malnutrition. Malnutrition has to be detected and treated because of its negative effects on morbidity and mortality. Dysphagia is one of the main causes of malnutrition, in particular if it do not regress rapidly. In this case, enteral nutrition is indicated and a gastrostomy is preferred if enteral nutrition has to be prolonged. In order to reduce morbidity and mortality, different nutritional interventions are yet to be evaluated.     

Nutrition et infertilité masculine : revue de la littérature

Infertility affects about 15% of couples. Many foctors relating to lifestyle and environment (drugs, alcohol, tobacco, pollution, exposure to heat, diet and sport…) are likely to influence fertility. As an adapted nutrition could prevent 30% of cancers, diet could be essential, but largely neglected, in the prevention of infertility. Some studies tried to explore the impact of diet on testis function and on semen quality, unfortunately rarely informative. Similarly, supplementation with vitamins or micronutrients, prescribed in order to improve sperm parameters, have rarely been validated by double-blind, randomized, placebo controlled studies. The aim of this review is to assess the role of nutrition in spermatogenesis and sperm maturation.     

Nutrition et maladie d’Alzheimer

Deterioration of memory function and ultimately establishment of Alzheimer's disease (AD) severely debilitates the affected individual, uncompromisingly decreasing the quality of life of both patients and their caregivers. The global prevalence of cognitive impairment and dementia including Alzheimer's disease is expected to rise significantly in proportion to increased life expectancy. Weight loss is a common problem among patients with AD and is associated with mortality, morbidity, disease progression, and poor quality of life. The aim of this article is: (1) to emphasize the importance of malnutrition in Alzheimer's disease and (2) to review published evidences for the role of nutrition as a risk factor of the disease.     

La consultation pré-anesthésique comme outil de dépistage nutritionnel préopératoire

Objective

In severely malnourished patients, preoperative nutritional support helps lessen the adverse impact of malnourishment on postoperative progress. An essential prerequisite is to identify this malnourishment. We wanted to find out whether pre-anaesthetic consultation (which is not compulsory in Belgium) was a tool that could be used to achieve these objectives of preoperative nutritional screening in patients undergoing abdominal surgery.

Method

Our working method comprised of three phases. Having conducted a study to determine our situation, we integrated the NRS 2002 into our computerised consultation protocol and created a procedure used to link our consultation with the dietetics consultation on the same day. We then analysed the effectiveness of our actions.

Results

We received 87.8% of patients undergoing elective abdominal surgery at the pre-anaesthetic consultation. Thanks to the computerisation of the NRS 2002, our nutritional screening rose from 60.8% to 86.1%. All patients at risk of malnutrition were referred to the dietetics service on the same day for a nutritional assessment and nutritional support if necessary. This procedure reduced the hospital re-admittance rate as much as possible. The average period of 13 to 15 days between the pre-anaesthetic consultation and the surgery was sufficient to put in place preoperative nutritional support.

Conclusion

Pre-anaesthetic consultation has therefore become a tool used for preoperative nutritional screening and care.     

La nutrition artificielle en periopératoire chez le patient diabétique

The diabetic patients are at high risk of malnutrition. One recommends seeking specific deficiencies (zinc, selenium, vitamins C and E) for malnourished diabetic patients. For the perioperative cares, one recommends to cover their protein needs and their caloric needs and to accordingly optimize the antidiabetic treatment. One should probably use oral supplements or enteral nutrition products with a low glycemic index. The presence of diabetic gastroparesis can make it difficult or dissuade enteral nutrition. The incidence of gastroparesis justifies gastric residue control, the use of prokinetic, and nutrition in postpyloric site. An equivalent parenteral carbohydrate intake has a hyperglycaemic effect more important than with the oral or enteral way. It is recommended to use an infusion pump in diabetic patients to administer parenteral nutrition. Daily use of lipid emulsions is recommended in this context.     

Place du diététicien dans l’équipe de soutien nutritionnel : évolution d’une profession

Recognised 30 years ago, hospital nutritional depletion remains a major problem of public health which concerns from 30% to 50% of all patients at admission. The circular DHOS/E 1 n? 2002-186 of the 29 March 2002, recommending the implementation of both the committee for food-nutrition (CLAN: Comité de Liaison Alimentation Nutrition) and the nutrition support team within the hospital, is the result of 10 years effort in regard to food-nutrition and the accreditation process in health care. The dietician, previously accountable for the quality of food and dietary services, has now the opportunity to play a leading role within the nutritional care team for the screening and treatment of nutritional depletion. However, the initial training and the present status of the dietician don’t allow him to follow this evolution effectively. Updating of his training and the redefinition of his missions seem indispensable to respond to today's health care needs. This will help to ensure that above legal recommendation can be applied.     

Polluants environnementaux et troubles de la reproduction masculine : les phtalates au cœur du débat

Two major functions are assumed by the testis: the production of male gametes (i.e. spermatozoa), and the production of steroid hormones. Those two functions are established during fetal life and are essentials for the adult fertility and the masculinization of the internal tract and genitalia. For many years, our laboratory has been interested in the ontogeny of those two functions in rodents and since 2003, in collaboration with Gynecology and Obstetrics service of Professor R. Frydman in A. Béclère hospital, we have studied them in human. The first aim of this work was to improve the global knowledge of the human fetal testis development by using both our experimental data and the literature. Then we focused on the different defects that can occur during the fetal testis development. Indeed, male reproductive abnormalities have been steadily increasing since the last decades and are thought to be related to the concomitant increase of the concentration of contaminants and particularly of endocrine disruptors in the environment. Thus, we decided to study the effect of endocrine disruptors on human fetal testis, and more particularly the effect of phthalates, by using an organ culture system developed for human. In contrast to the data obtained in rat, mono (ethylhexyl)-phthalate (MEHP), an active metabolite of the most widespread phthalate in the environment, does not disturb the steroidogenic function. On the other hand, it has a negative effect on the male germ cells number. This study is the first experimental demonstration of a negative effect of phthalates directly on human reproductive functions. Using a molecular approach, our aim is now to understand the mechanisms of phthalate's action.     

Nutrition des traumatisés crâniens graves

Traumatic injury and severe brain injuries in particular, have systemic consequences affecting all major functions. As energy expenditure increases, energy needs are covered by gluconeogenesis from muscle protein even if they are modulated by the use of different drugs. A gradual erosion of protein reserves results in an acute state of malnutrition exacerbating the immunosuppression induced by trauma, and facilitates infection. Artificial nutrition may limit this process. Gastric feeding route should be initiated early and guided by a written protocol. Gastroparesis being one of the main causes of failure of this route, it must be quickly identified, before calorie deficit harms patients. Nasojejunal tube or parenteral nutrition must be then considered in order to cover nutritional requirements which correspond to about 20–25 kcal/kg per day during the initial phase, and up to 30 kcal/kg per day during the recovery period. Sepsis, agitation or autonomic dysfunction syndromes may increase nutritional requirements. Their evaluation can be improved by mathematical formulas or calorimetry in complex situations (obesity…). Despite the intensity of muscle catabolism, protein intake should be approximately 1.5 g/kg per day. Furthermore, trauma is associated with depletion of glutamine, some vitamins and trace elements including selenium. Supplementation of glutamine reduces infectious morbidity. It must be given at a sufficient dosage and may be associated with selenium. Finally, an adequate glycemic control is essential to avoid brain damage.     

Dépistage tardif de l’infection à VIH à la clinique des maladies infectieuses de Fann,Dakar : circonstances de diagnostic,itinéraire thérapeutique des patients et facteurs déterminants

Background and methodology

The delay in the diagnosis of HIV infection is a major obstacle to optimal care for this disease. To deal with this problem, we conducted this study among newly diagnosed HIV patients hospitalized in the Fann University Hospital Infectious Diseases Clinic in Dakar. The epidemiological, clinical, biological and outcome aspects are described and patient history reviewed. A qualitative socio-anthropological study was made to understand and describe the logic of the decision processes in the patient's search for treatment.

Results

One hundred patients were included, with a mean age of 39.5 ± 11.1 years and a sex-ratio: 1.08. The transmission was mainly heterosexual (90%), and chronic diarrhea (64%) and/or chronic cough (66%) were the principal symptoms leading to diagnosis. The mean delay before diagnosis was 5 ± 4.27 months. The major opportunistic diseases were tuberculosis (44 cases) and infectious diarrhea (23 cases). Most patients were diagnosed at the AIDS stage (97%) and the death rate was 30% among hospitalized patients after admission. Sixty-eight percent of patients had consulted at least three times, generally a “traditional practitioner”, at first and 43% had been hospitalized at least once. The qualitative investigation revealed that the “representation” or the “feeling of severity” of the disease were the principal justifications for consulting the “traditional practitioner” or the physician, respectively.

Conclusion

Better information for health workers and global population is necessary for an earlier diagnosis of HIV infection in Dakar.     

Les progrès de l'alimentation animale pour satisfaire les critères de qualité : du producteur au consommateur !

Consumers’expectations have drastically changed over the last twenty years. Animal products are more and more transformed into ready-to-cook even ready-to-eat products. To the performance target, have been added consumers’desires such as quality, health and transformers’constraints for homogeneity and capacity for further processing. The nutritionist becomes the scientist of the compromise. He has to reach performance with quality with the help of feed complements and additives such as amino acids, vitamins, trace minerals. He can use rapid evaluation tool to adapt complementation to the actual batch of raw materials as well as exogenous enzymes to better access the valuable nutrients. By modifying the feeding strategy and feed composition, the nutritionist is able to contribute to satisfy human needs: from polyunsaturated fatty acids to vitamins and health benefits. Furthermore, the overall target is to guarantee the sustainability of animal productions.     

Évaluation et prise en charge des troubles de la déglutition

Swallowing is a complex phenomenon, allowing per os feeding but with a protection of respiratory tract. Swallowing disorders are frequent, involve liquids, solids or theses two textures, and are mainly caused by neurological or otorhinolaryngological diseases. They may have severe consequences, like an alteration of quality of life for patients or their relatives, an increased risk of aspiration, of malnutrition or dehydration, and finally a possible decrease of survival. Assessment includes careful questioning and physical examination. The reference complementary investigation is videofluoroscopic evaluation. Nutritional assessment is mandatory. Taking care of swallowing disorders in a multidisciplinary manner is recommended, with interventions of physician, speech therapist, dietician, sometimes dentist or surgeon, and needs a strong contribution of the paramedical staff and the patient relatives. Enteral nutrition is recommended when repeated or severe respiratory complications occur, when the nutritional status is altered in spite of feeding enrichment, modulations of textures or use of oral nutritional supplements, or when the meals are too long.     

Suppression de la collation matinale au sein des écoles maternelles de franche-comté : bilan de 3 ans d’actions dans le cadre du pnns

As part of the national nutrition health programme (PNNS), the Region of Franche-Comté (France) has initiated, between 2002 and 2005, a cycle of conferences, either to modify (in a department), or to remove (in the 3 others) the morning collation within the nursery schools (3-5 years old) following in that the national recommendations. Thirty conferences were organized and nearly 4 000 teachers were joined. Organized by 99% of the schools in 2002, this collation is proposed more into 2005 only by 59% of them with strong departmental differences. In the situations of maintenance of the collation, the contents proposed evolved favourably in more than 3 schools out of 4. This action shows that the modifications of professional practices, however firmly anchored, are possible and that the suppression of this meal is on hand in Franche-Comté. This initiative also makes it possible to insist on the major role of certain total public health programme like the PNNS and on the importance to accompany the implementation by the official texts by a work of explanation of proximity.     

Prévention et prise en charge de la dénutrition dans les EHPAD

In order to identify best practices for undernutrition prevention and management in the 597 institutions for the dependent elderly in Pays de la Loire, two questionnaires were sent in early 2009. Three-quarters had a nutritional axis in their care project, 25% worked with a Diet and Nutrition Liaison Committee (CLAN), and 67% with dieticians; 70% had less than 25% of their staff recently trained to food-nutrition for the elderly. Two thirds were conducting detection of malnutrition at admission and during follow-up. There was enough time for meals in 60% cases, and 48% had all their residents who underwent a long overnight fast. Among beneficial environmental factors identified, the nutritional axis in the care project seemed to be a major determinant of food-nutrition practices. In conclusion, these results show the real structures involvement in this field in the region, but some practices must be further improved. Nutritional policies seem to be a major way to achieve.