Réhabilitation précoce après césarienne programmée : enquête de pratique auprès des maternités des régions Provence - Alpes - Côte d’Azur et Île-de-France

Aims

Although most components of an enhanced recovery programme (ERP) can be applied to caesarean delivery, it is unknown if their implementation is large in France.

Type of study

Structured interview by telephone or e-mailing of an anaesthetist to describe usual perioperative practice in two French regions (Provence - Alpes - Côte d’Azur [PACA] and Île-de-France [IDF]).

Methods

Questionnaire related to scheduled caesarean delivery.

Results

Response rate 74% (111/149 maternity units). Multimodal analgesia was almost universally applied and intrathecal/epidural morphine used by 86% of respondents. Oral administration of analgesic drugs was started before h24 in 50% of responding units and immediately after delivery in 7% of them. The urinary catheter was withdrawn after h24 in 71% of responding centres. Women were allowed to drink between h4 and h6 (60%), in an unlimited amount (79%). The first meal was authorised after h6 (89%) but before h24 (65%) or after recovery of bowel function (13%). Oxytocin was used in 69% of respondents and maintained postoperatively for 12 to 24 hours (70% of oxytocin users). Carbetocin was used in the remaining 31%, usually without any maintenance oxytocic drug. Attributing one point to each major component of the ERP protocol (0–6), the median value was 3 (2–4). An ERP protocol was available in 14% of responding units and was associated with a shorter duration of intravenous and urinary catheters use.

Conclusion

The study shows that the components of an ERP are insufficiently implemented in France after caesarean delivery. Moreover, significant heterogeneity exists between maternity units and among regions.     

Une nouvelle prise en charge de la sphère oro-faciale des enfants paralysés cérébraux par un jeu interactif en 3D

Rehabilitation of facial praxia in children affected by cerebral palsy is an important goal, although its efficiency remains hard to evaluate. We have listed difficulties encountered by a child during a session of classical rehabilitation, and we propose a novel technique of rehabilitation based on the use of an interactive avatar. In addition to the game-like use of this interactive tool, motions captures that will be recorded during work sessions will also be usable to get metric measurements of the buccofacial movements of children with cerebral palsy. For each child, we will be able to define their own characteristics, which will probably reflect the great heterogeneity of clinical aspects and movements developed by these children. This study will require that each patient will be his own control to evaluate the efficiency of this new protocol.     

Les systèmes et niveaux de détermination du comportement alimentaire

Eating behaviours are ruled simultaneously by physiological; psychological, technical, social, and economic systems. In practice, human subjects manage the complexity of these multiple determinants by following mental and technical routines, which progressively incorporate the results of experience. Social representations are a key mode of transmission and guidance of behaviour; a kind of user’s manual of everyday objects. To modify behaviour, one has to act simultaneously upon all levels of determination in order to open new behavioural paths, and this can be done only in collaborative process involving all stakeholders.     

Le sel : vigilance dans la première année de vie*

For infants, sodium recommended dietary allowances are low. The influence of sodium intake on young children's blood pressure has been shown contradictory. Sodium intake increases as children get older from 2 months, 5 months, 9 months, 12 months. This is especially influenced by complementary foods. Moreover, sodium intake can also vary by a factor of 2 at any time period, depending on food choice, i.e. milk formula, baby's food and even usual family's food. In addition no benefit is expected from a high level sodium intake; an excessive sodium intake is often linked in toddler's food to an excess intake of protein and saturated fatty acids. That's why it seems safer to limit sodium level consumption. Therefore nutritional information has to be organised for mothers and caregivers in maternity wards and in day care centers to promote healthy food habits in early childhood.     

Enteral feeding by nasogastric tube in mandibular fracture osteosynthesis

INTRODUCTION: Mandibular fractures are among the most common fractures of the face; their treatment consists in a reduction by intermaxillary blocking then miniplate osteosynthesis. In our unit we systematically insert a nasogastric tube for enteral feeding to improve nutrition and to protect healing. Since the beginning of 2002, a series of patients operated for simple mandibular fractures were fed immediately after the operation by a semiliquid food. The purpose of this work is to verify the real advantage of enteral feeding by nasogastric tube in patients operated for simple fractures of the mandible. MATERIAL AND METHOD: This retrospective study includes all the patients operated for closed fractures of the toothed portion of the mandible from January 1999 to October 2003. There were two series, a first series of patients operated between 1999 and 2002 fed by nasogastric tube until mouth healing and the second series of patients operated between 2002 and 2003 fed by mixed oral-enteral nutrition from the first postoperative day. We analyzed demographic features, time between trauma and operation, type of fracture, feeding modalities, duration of use of the nasogastric tube, duration of hospital stay and postoperative complications. RESULTS: A total of 111 patients were included in the study. The first group of 81 patients fed by nasogastric tubes included 19 women and 62 men with an average age of 29.7 years (from 15 to 81 years).The average time from trauma to operation was 2.3 days (0 to 5 days), the feeding by nasogastric tubes was maintained 5.9 days after the operation (4 to 12 days), the average hospital stay was 7.2 days (5 to 13 days). Eleven immediate complications were observed (13.6%). The second group of 30 patients fed orally the day after the intervention included 7 women and 23 men. The average time from trauma to operation was 2.2 days (0 to 7 days), the average hospital stay was 2.5 days (2 to 3 days). One complication was observed (3.3%). DISCUSSION: Immediate oral feeding the day after the operation for simple closed mandibular fractures provides certain comfort for the patient by avoiding the inconveniences of nasogastric feeding tubes without increasing the rate of postoperative complications such as disunion, delayed healing or infection. The hospital stay is significant shortened, enabling a real cost savings.     

Nutrition et ostéoporose

Osteoporosis is a global public health problem which currently affects approximately 40% of caucasien women and 13% of men, and is increasing, as the population is living longer. Moreover, osteoporosis fractures are a significant cause of disability and premature death. This disease is a complex, multifactorial chronic disorder in which a variety of pathophysiologic mechanisms lead to skeletal fragility. Because hypoestrogenemia after menopause is an important cause of osteoporosis, hormone replacement therapy was recommended. However, because of side effects, women and health professionals became reluctant to this prophylaxis. Thus, increased research into alternatives, in particular nutritional strategies, for optimising bone health is of clinical, scientific and health policy importance. In general, the two key nutrients to consider for bone health are the mineral calcium and vitamin D. However, it has been recognised that the human diet contains, in addition to essential macronutrients (protein, lipids…), a complex array of naturally occurring bioactive molecules, the phytochemicals endowed with ostrogenic, antioxidant and anti-inflammatory properties, which could play an important clue in osteoporosis prevention.     

Bases nutritionnelles pour un vieillissement réussi

Aging is an inevitable biological feature of living organisms. Moreover, human lifespan is increasing. In last years, many studies featured a molecular basis and biological events that contribute to the progressive decline in cellular functioning at the time of senescence.The aging itself may be at the origin of various states that render this population very heterogeneous because subjects, at equivalent age, can be: in a state of good health at home, active - “fragile”, less active and at risk of diseases - ill, acute or chronic, dependent or independent. But they can also benefit from “successful aging” described for the first time by Rowe and Kahn in 1987 as an aging without disease or handicap, allowing a high level of physical activity and cognitive function and accompanied by an engagement and activities in the social life. The optimal nutrition is one of the most accessible modifiable factors to module the aging by means of targeted strategies in order to favor a successful aging. One of the first is the identification of persons at risk of nutritional diseases, either being by overcharge or by defects, and even by deficiencies such as denutrition. Because of physiological changes linked to aging itself can reach the capacities of eating and cause consequences on the nutritional state: loss of appetite, precocious satiety, and decreased taste perception. The nutrition plays a role on practically all factors of senescence. We will limit the subject to some fundamental mechanisms on which the nutritional impact is recognized: insulin resistance, oxidative stress, stabilization of the weight and the loss of the muscular mass called sarcopenia whose consequences are deleterious. Two levers for action are synergetic: the alimentation and the moderate physical exercise which improves its efficiency. Some practical means will then be proposed to equilibrate food, on the sight of the study results, that follows Euronut-Seneca, Healthy Aging: Longitudinal Study in Europe (HALE) which proposes a multi disciplinary approach to the successful aging and to its determinants in 11 European countries, by featuring the positive factors of successful aging in volunteers having reached a long longevity, in a good state of physical and psychological health… These advises are also those allowing to preserve a good cardiovascular, metabolic, and even vascular cerebral state, so a good cognitive status.Finally, to preserve the status in micronutrients, without hoping that global alimentary supplements allow compensating all deficiencies due to the aberrant alimentations, in particular restrictive. The epidemiological studies show that subjects taking the most of supplements are those having no deficits… in particular in antioxidatives, which increases the risk of limiting the necessary apoptosis of damaged cells.In conclusion: to conserve the desire to eat, a varied diet in moderation, in convivial manner each time is possible and without monotony which is deleterious for alimentation like sedentarity for physical well-being.     

Alimentation méditerranéenne et maladies cardiovasculaires: analyse des études d’intervention

The recent traditional Mediterranean diet, as studied in 1950-60s in the South of Europe is characterized by moderate energy intake, low animal fat, high olive oil, high cereals, high legumes, nuts and vegetables, regular and moderate wine. The Seven country study and several more recent studies conducted in Greece and Spain have established the concept that traditional Mediterranean diet is beneficial for health and particularly protects against cardiovascular disease. For primary prevention in subjects at risk as well as for secondary prevention in patients with cardiovascular disease, mediterraean-type diets have shown beneficial protective effects as reviewed in details in this paper. Nevertheless, during the last decades, dietary habits have markedly evolved in the Mediterranean area, leading to a progressive and marked drop in observance to the traditional Mediterranean diet. Thus, important efforts have to be made to counteract this detrimental trend and to update and popularize the use of Mediterranean diet for health benefit.