Pauline Coti Bertrand

Preoperative immunonutrition in patients at nutritional risk: results of a double-blinded randomized clinical trial.

Background/Objectives:To evaluate the impact of preoperative immunonutrition (IN) on postoperative morbidity in patients at risk of malnutrition undergoing major gastrointestinal (GI) surgery.Subjects/Methods:The combination of malnutrition and major GI surgery entails high morbidity. The Nutritional Risk Score (NRS) reliably identifies patients who need preoperative nutrition; the optimal nutritional formula for these patients still needs to be defined. In all, 152 patients with a NRS⩾3 and undergoing elective major GI surgery were randomized between IN or isocaloric-isonitrogenous nutrition (ICN) given for 5 days preoperatively. Patients and caregivers were blinded for the allocated intervention. Thirty days complication rate was the primary endpoint. Infections, length of hospital stay and compliance were considered as secondary outcomes.Results:Overall, 145 patients were available for analysis; the 73 patients in the IN group matched well with the 72 ICN patients with regards to patients and surgical characteristics. In all, 39 IN and 33 ICN patients experienced a total of 48 and 50 postoperative complications, respectively (P=0.723). Both groups did not differ significantly concerning infectious (13 vs 9) complications. Independent risk factors for overall complications were malignant disease (odds ratio (OR)=4.304; confidence interval (CI) 1.317–14.002) and operative time (OR=1.004; CI 1.000–1.008).Conclusion:In patients at nutritional risk, complications, infections and hospital stay after major GI surgery were comparable regardless of preoperative supplementation with IN or ICN.

Effect of Intradialytic Resistance Band Exercise on Physical Function in Patients on Maintenance Hemodialysis: A Pilot Study

Although physical activity is recommended in patients on maintenance hemodialysis (MHD), randomized controlled trials testing the effects of exercise in this population have given conflicting results. In general, aerobic exercises mostly failed to produce improvements in physical function, whereas resistance exercises, although less studied, appeared to be more promising. The use of sophisticated materials such as leg press and free weights may preclude widespread application of resistance training in patients on MHD. Simple and cheap elastic bands may thus be an attractive alternative. We tested the feasibility of a supervised intradialytic resistance band exercise training program, and its effects on physical function, in patients on MHD. A total of 11 unselected adult patients on MHD from our center, aged 70 ± 10.7 (mean ± standard deviation) years, including 8 men and 3 women, accepted to follow the program under the supervision of qualified physiotherapists. Thirty-six exercise sessions of moderate intensity (twice a week, mean duration 40 minutes each, during 4.5 to 6 months), mainly involving leg muscles against an elastic resistance, were performed. The exercise program was well tolerated and all patients completed it. Statistically significant improvements were observed in the following tests: Tinetti test, 23.9 ± 3.9 points before versus 25.7 ± 3.5 points after the program (P = .022); the Timed Up and Go test, 12.1 ± 6.6 versus 10 ± 5.8 seconds (P = .0156). Improvements in the 6-minute walk distance and in the one-leg balance tests just failed to reach statistical significance. In this single-center pilot study, an intradialytic resistance band exercise program was feasible, well tolerated, and showed encouraging results on physical function.

Compliance with preoperative oral nutritional supplements in patients at nutritional risk─only a question of will?

Background/Objectives:Preoperative nutrition has been shown to reduce morbidity after major gastrointestinal (GI) surgery in selected patients at risk. In a randomized trial performed recently (NCT00512213), almost half of the patients, however, did not consume the recommended dose of nutritional intervention. The present study aimed to identify the risk factors for noncompliance.Subjects/Methods:Demographic (n=5) and nutritional (n=21) parameters for this retrospective analysis were obtained from a prospectively maintained database. The outcome of interest was compliance with the allocated intervention (ingestion of ⩾11/15 preoperative oral nutritional supplement units). Uni- and multivariate analyses of potential risk factors for noncompliance were performed.Results:The final analysis included 141 patients with complete data sets for the purpose of the study. Fifty-nine patients (42%) were considered noncompliant. Univariate analysis identified low C-reactive protein levels (P=0.015), decreased recent food intake (P=0.032) and, as a trend, low hemoglobin (P=0.065) and low pre-albumin (P=0.056) levels as risk factors for decreased compliance. However, none of them was retained as an independent risk factor after multivariate analysis. Interestingly, 17 potential explanatory parameters, such as upper GI cancer, weight loss, reduced appetite or co-morbidities, did not show any significant correlation with reduced intake of nutritional supplements.Conclusions:Reduced compliance with preoperative nutritional interventions remains a major issue because the expected benefit depends on the actual intake. Seemingly, obvious reasons could not be retained as valid explanations. Compliance seems thus to be primarily a question of will and information; the importance of nutritional supplementation needs to be emphasized by specific patients’ education.

Visual Sensorial Impairments in Neurodevelopmental Disorders: Evidence for a Retinal Phenotype in Fragile X Syndrome

Visual sensory impairments are common in Mental Deficiency (MD) and Autism Spectrum Disorder (ASD). These defects are linked to cerebral dysfunction in the visual cortical area characterized by the deregulation of axon growth/guidance and dendrite spine immaturity of neurons. However, visual perception had not been addressed, although the retina is part of the central nervous system with a common embryonic origin. Therefore, we investigated retinal perception, the first event of vision, in a murine model of MD with autistic features. We document that retinal function is altered in Fmr1 KO mice, a model of human Fragile X Syndrome. Indeed, In Fmr1 KO mice had a lower retinal function characterized by a decreased photoreceptors neuron response, due to a 40% decrease in Rhodopsin content and to Rod Outer Segment destabilization. In addition, we observed an alteration of the visual signal transmission between photoreceptors and the inner retina which could be attributed to deregulations of pre- and post- synaptic proteins resulting in retinal neurons synaptic destabilization and to retinal neurons immaturity. Thus, for the first time, we demonstrated that retinal perception is altered in a murine model of MD with autistic features and that there are strong similarities between cerebral and retinal cellular and molecular defects. Our results suggest that both visual perception and integration must be taken into account in assessing visual sensory impairments in MD and ASD.

Nutritional Status Deteriorates Postoperatively Despite Preoperative Nutritional Support

Background/Aims: The aim of the current study was to assess the postoperative evolution of nutritional status and to relate it with postoperative outcomes. Methods: Demographic, surgical and nutritional parameters were assessed 10 days preoperatively (d-10) and 30 days postoperatively (d30) in 146 patients. Risk factors responsible for perioperative (>5% between d-10 and d30) weight loss were identified. Overall, severe (Clavien 3-5) and infectious complications were compared in patients with and without perioperative weight loss (>5%). Results: Nutritional status worsened beyond the postoperative period as reflected by decreasing weight (67 ± 13 kg at d-10 vs. 63 ± 13 kg at d30, p < 0.001), body mass index (23.4 ± 4 vs. 22.2 ± 4 kg/m2, p < 0.001) and mid upper-arm muscle circumference (MAMC, 241 ± 32 vs. 232 ± 30 mm, p < 0.001). Fifty-two patients (46%) lost >5% of their body weight between d-10 and d30. Patients who presented overall (63 vs. 36%, p = 0.004) and major (27 vs. 10%, p = 0.016) postoperative complications were at significantly higher risk to deteriorate postoperative nutritional status. Multivariate analysis identified low preoperative lean body mass (OR 3.2; 95% CI 1.2-8.9, p = 0.023) and low preoperative MAMC (OR 2.5; 95% CI 0.9-6.8, p = 0.066) as independent risk factors for perioperative weight loss. Conclusions: These data suggest continuing nutritional follow-up after the index hospitalization.

Preoperative nutritional screening by the specialist instead of the nutritional risk score might prevent excess nutrition: a multivariate analysis of nutritional risk factors

BackgroundThe aim of the current study was to assess whether widely used nutritional parameters are correlated with the nutritional risk score (NRS-2002) to identify postoperative morbidity and to evaluate the role of nutritionists in nutritional assessment.MethodsA randomized trial on preoperative nutritional interventions (NCT00512213) provided the study cohort of 152 patients at nutritional risk (NRS-2002 ≥3) with a comprehensive phenotyping including diverse nutritional parameters (n=17), elaborated by nutritional specialists, and potential demographic and surgical (n=5) confounders. Risk factors for overall, severe (Dindo-Clavien 3-5) and infectious complications were identified by univariate analysis; parameters with P<0.20 were then entered in a multiple logistic regression model.ResultsFinal analysis included 140 patients with complete datasets. Of these, 61 patients (43.6%) were overweight, and 72 patients (51.4%) experienced at least one complication of any degree of severity. Univariate analysis identified a correlation between few (≤3) active co-morbidities (OR=4.94; 95% CI: 1.47-16.56, p=0.01) and overall complications. Patients screened as being malnourished by nutritional specialists presented less overall complications compared to the not malnourished (OR=0.47; 95% CI: 0.22-0.97, p=0.043). Severe postoperative complications occurred more often in patients with low lean body mass (OR=1.06; 95% CI: 1-1.12, p=0.028). Few (≤3) active co-morbidities (OR=8.8; 95% CI: 1.12-68.99, p=0.008) were related with postoperative infections. Patients screened as being malnourished by nutritional specialists presented less infectious complications (OR=0.28; 95% CI: 0.1-0.78), p=0.014) as compared to the not malnourished.Multivariate analysis identified few co-morbidities (OR=6.33; 95% CI: 1.75-22.84, p=0.005), low weight loss (OR=1.08; 95% CI: 1.02-1.14, p=0.006) and low hemoglobin concentration (OR=2.84; 95% CI: 1.22-6.59, p=0.021) as independent risk factors for overall postoperative complications. Compliance with nutritional supplements (OR=0.37; 95% CI: 0.14-0.97, p=0.041) and supplementation of malnourished patients as assessed by nutritional specialists (OR=0.24; 95% CI: 0.08-0.69, p=0.009) were independently associated with decreased infectious complications.ConclusionsNutritional support based upon NRS-2002 screening might result in overnutrition, with potentially deleterious clinical consequences. We emphasize the importance of detailed assessment of the nutritional status by a dedicated specialist before deciding on early nutritional intervention for patients with an initial NRS-2002 score of ≥3.

Pioglitazone Improves Fat Distribution, the Adipokine Profile and Hepatic Insulin Sensitivity in Non-Diabetic End-Stage Renal Disease Subjects on Maintenance Dialysis: A Randomized Cross-Over Pilot Study

Background Fat redistribution, increased inflammation and insulin resistance are prevalent in non-diabetic subjects treated with maintenance dialysis. The aim of this study was to test whether pioglitazone, a powerful insulin sensitizer, alters body fat distribution and adipokine secretion in these subjects and whether it is associated with improved insulin sensitivity. Trial Design This was a double blind cross-over study with 16 weeks of pioglitazone 45 mg vs placebo involving 12 subjects. Methods At the end of each phase, body composition (anthropometric measurements, dual energy X-ray absorptometry (DEXA), abdominal CT), hepatic and muscle insulin sensitivity (2-step hyperinsulinemic euglycemic clamp with 2H2-glucose) were measured and fasting blood adipokines and cardiometabolic risk markers were monitored. Results Four months treatment with pioglitazone had no effect on total body weight or total fat but decreased the visceral/sub-cutaneous adipose tissue ratio by 16% and decreased the leptin/adiponectin (L/A) ratio from 3.63×10−3 to 0.76×10−3. This was associated with a 20% increase in hepatic insulin sensitivity without changes in muscle insulin sensitivity, a 12% increase in HDL cholesterol and a 50% decrease in CRP. Conclusions/Limitations Pioglitazone significantly changes the visceral-subcutaneous fat distribution and plasma L/A ratio in non diabetic subjects on maintenance dialysis. This was associated with improved hepatic insulin sensitivity and a reduction of cardio-metabolic risk markers. Whether these effects may improve the outcome of non diabetic end-stage renal disease subjects on maintenance dialysis still needs further evaluation. Trial Registration ClinicalTrial.gov NCT01253928

Improving nutritional care quality in the orthopedic ward of a Septic Surgery Center by implementing a preventive nutritional policy using the Nutritional Risk Score: a pilot study

Background/ObjectivesSeptic Surgery Center (SSC) patients are at a particularly high risk of protein-energy malnutrition (PEM), with a prevalence of 35–85% found in various studies. Previous collaboration between our hospital’s SSC and its Clinical Nutrition Team (CNT) only focussed on patients with severe PEM. This study aimed to determine whether it was possible to improve the quality of nutritional care in septic surgery patients with help of a nutritional policy using the Nutritional Risk Score (NRS).Subjects/MethodsNutritional practices in the SSC were observed over three separate periods: in the 3 months leading up to the implementation baseline, 6 months after implementation of preventive nutritional practices, and at 3 years. The nutritional care quality indicator was the percentage of patients whose nutritional care, as prescribed by the SSC, was adapted to their specific requirements. We determined the septic surgery team’s NRS completion rate and calculated the nutritional policy’s impact on SSC length of stay. Data before (T0) and after (T1 + T2) implementation of the nutritional policy were compared.ResultsNinety-eight patients were included. The nutritional care-quality indicator improved from 26 to 81% between T0 and T2. During the T1 and T2 audits, septic surgery nurses calculated NRS for 100% and 97% of patients, respectively. Excluding patients with severe PEM, SSC length of stay was significantly reduced by 23 days (p = 0.005).ConclusionsThese findings showed that implementing a nutritional policy in an SSC is possible with the help of an algorithm including an easy-to-use tool like the NRS.

Contents Vol. 68, 2016

A. Astrup, Copenhagen A. Berg, Freiburg Z.A. Bhutta, Karachi S.C. Bischoff, Stuttgart F. Branca, Rome R. Brigelius-Flohé, Nuthetal P.C. Calder, Southampton S. Carlson, Kansas City, Mo. I. Cetin, Milan R.J. Deckelbaum, New York, N.Y. T. Decsi, Pécs C.J. Field, Edmonton, Alta. K. Godfrey, Southampton R. Hakkak, Little Rock, Ark. W.S. Harris, Sioux Falls, S. Dak. H. Hauner, Munich M. Hernández-Triana, Havana H. Heseker, Paderborn N. Hiki, Tokyo E. Hypponen, London Y. Kido, Kyoto W. Kimura, Yamagata J. Kopecky, Prague M. Krawinkel, Giessen M. Lamprecht, Graz W. Langhans, Zurich D. Li, Hangzhou J. Linseisen, Neuherberg O. Ljungqvist, Örebro Founded 1959 as ‘Nutritio et Dieta’ by E. Azerad, H. Kapp and J. Trémolières. Continued by A. Wretlind (1961–1969). Continued by N. Zöllner (1970–1990) as ‘Nutrition and Metabolism’ (1970–1980), since 1980 integrating ‘Annales de la Nutrition et de l’Alimentation’, continued as ‘Annals of Nutrition and Metabolism’. Continued by G. Wolfram (1991–1999), Continued by I. Elmadfa (2000–2010) Official Journal of International Union of Nutritional Sciences (IUNS) Federation of European Nutrition Societies (FENS) Japanese Society for Parenteral & Enteral Nutrition (JSPEN) Deutsche Gesellschaft für Ernährung (DGE)