Evolution de l'autonomie fonctionnelle et des capacités d'auto-soins des patients âgés hospitalisés en médecine gériatrique : mieux comprendre pour mieux agir en soins infirmiers

De part le vieillissement démographique, la proportion de personnes âgées augmente et, certaines d'entre-elles nécessiteront des soins en milieu hospitalier. Chez l'aîné, l'expérience d'une maladie et d'une hospitalisation augmente le risque de perte d'autonomie dans les activités de la vie quotidienne (AVQ) et peut compromettre le retour à domicile, diminuer la qualité de vie et mobiliser des ressources du système socio-sanitaire. En Suisse, une étude a établi l'ampleur du problème de la dépendance dans les AVQ à domicile. Cependant, peu de connaissances récentes sont disponibles sur la perte d'autonomie à l'hôpital et aucune sur les trajectoires dans les AVQ. But : Le but de cette étude est d'actualiser et compléter les savoirs sur la perte d'autonomie et les trajectoires dans les AVQ des personnes âgées hospitalisées dans un hôpital tertiaire de Suisse romande. Cadre théorique : La présente étude se base sur la théorie du déficit en auto-soin de Dorothea Orem. Méthode : Cette étude descriptive corrélationnelle est une analyse secondaire des données recueillies dans l'unité pilote du projet Soins Aigus aux Séniors entre août 2011 et janvier 2012. Le déficit en auto-soin dans les AVQ a été mesuré avec l'Index de Katz, les habiletés de base avec le MiniCog, le MiniGDS et le CAM et, les facteurs prédisposant étaient l'âge, le genre, l'entourage et l'aide à domicile ainsi que l'état de santé. L'échantillon de 209 patients présentait un âge moyen de 85.4 ans (SD 7.2) et une proportion de 72.7% de femmes. Résultats : Les principaux résultats montrent que la majorité des patients ont une perte d'autonomie dans les AVQ avant l'admission à l'hôpital (56.2%) et que près d'un patient sur six (14.5%) continue d'expérimenter un déficit en auto-soin durant l'hospitalisation. Les facteurs prédisposant à une trajectoire de déficit en auto-soin entre le domicile et la sortie de l'hôpital identifiés ont été : l'état confusionnel aigu (OR=6.00, IC 95% 1.83 - 19.63), la dépendance en auto-soin à domicile (OR=1.44, IC 95% 1.02 - 2.02) et, une trajectoire de déficit en auto-soin entre le domicile et l'entrée à l'hôpital (OR=14.82, IC 95% 4.83 - 45.46). Conclusion : Cette étude met en évidence que les personnes âgées hospitalisées expérimentent des déficits dans les AVQ et qu'un des facteurs favorisants est la présence d'un état confusionnel aigu. D'autres recherches sont nécessaires pour renforcer et compléter ces résultats.

Vestibular Schwannoma: The Evolution of Hearing and Tumor Size in Natural Course and after Treatment by LINAC Stereotactic Radiosurgery.

OBJECTIVE: To review the natural course of tumor size and hearing during conservative management of 151 patients with unilateral vestibular schwannoma (VS), and to evaluate the same parameters for the part of the group (n = 84) who were treated by LINAC stereotactic radiosurgery (SRS). METHODS: In prospectively collected data, patients underwent MRI and complete audiovestibular tests at inclusion, during the conservative management period and after SRS. Hearing was graded according to the Gardner-Robertson (GR) scale and tumor size according to Koos. Statistics were performed using Kaplan-Meier survival analysis and multivariate analyses including linear and logistic regression. Specific insight was given to patients with serviceable hearing. RESULTS: During the conservative management period (mean follow-up time: 24 months, range: 6-96), the annual risk of GR class degradation was 6% for GRI and 15% for GR II patients. Hearing loss as an initial symptom was highly predictive of further hearing loss (p = 0.003). Tumor growth reached 25%. For SRS patients, functional hearing preservation was 51% at 1 year and 36% at 3 years. Tumor control was 94 and 91%, respectively. CONCLUSION: In VS patients, hearing loss at the time of diagnosis is a predictor of poorer hearing outcome. LINAC SRS is efficient for tumor control. Patients who preserved their pretreatment hearing presented less hearing loss per year after SRS than before treatment, suggesting a protective effect of SRS when cochlear function can be preserved.

Why evolution matters for species conservation: perspectives from three case studies of plant metapopulations

We advocate the advantage of an evolutionary approach to conservation biology that considers evolutionary history at various levels of biological organization. We review work on three separate plant taxa, spanning from one to multiple decades, illustrating extremes in metapopulation functioning. We show how the rare endemics Centaurea corymbosa (Clape Massif, France) and Brassica insularis in Corsica (France) may be caught in an evolutionary trap: disruption of metapopulation functioning due to lack of colonization of new sites may have counterselected traits such as dispersal ability or self-compatibility, making these species particularly vulnerable to any disturbance. The third case study concerns the evolution of life history strategies in the highly diverse genus Leucadendron of the South African fynbos. There, fire disturbance and the recolonization phase after fires are so integral to the functioning of populations that recruitment of new individuals is conditioned by fire. We show how past adaptation to different fire regimes and climatic constraints make species with different life history syndromes more or less vulnerable to global changes. These different case studies suggest that management strategies should promote evolutionary potential and evolutionary processes to better protect extant biodiversity and biodiversification.

Evolution of the Helvetic shelf (Switzerland) during the Barremian-early Aptian : paleoenvironmental, paleogeographic and paleoceanographic controlling factors

The Early Cretaceous has experienced the development of large shallow-water carbonate platform in tropical and subtropical regions, favoured by exceptionally warm climatic conditions, optimal trophic conditions and a suitable tectonic and paleogeographic context. This period was also characterized by shorter intervals, in which the widespread deposition of marine sediments enriched in organic matter occurred ("oceanic anoxic episodes": OAE). This study focuses on the Barremian- Aptian interval, during which the Urgonian platform developed throughout the northern Tethyan passive margin. Due to the Alpine orogeny, sediments belonging to this platform - named locally Schrattenkalk Formation, are presently outcropping in the Helvetic Alps. This study aims to reconstruct the paleogeographic evolution of the Helvetic platform, and to define the environmental and oceanographic factors, which influenced its development. Several key episodes in the life of this platform have been identified: - The installation of the platform, covering hemipelagic sediments of the Drusberg Member, near the limit between the early and late Barremian. - The temporary change of carbonate production type during the basal Aptian, with the deposition of the Rawil Member. - And finally the definitive interruption of photozoan carbonate platform sedimentation in the study area, during the early Aptian. The sedimentological, biostratigraphical and chemostratigraphic (8I3C) data lead to the sequential subdivision of eleven sections and one core, located throughout the different Helvetic nappes of Switzerland. The sequence stratigraphie framework, initially defined for the Urgonian carbonate platform of the Vercors area (SE France), is confirmed in the Helvetic nappes, where the same number of sequences was observed. Many similarities between these two areas are put forward in this work. The sequence stratigraphie framework helped to highlight the installation of a bioclastic body, included in the Schrattenkalk Formation, since the middle Early Barremian (sequence B2). The age of the installation of the rudist-rich limestone, which corresponds to the Urgonian facies sensu stricto, is attributed to the late Barremian (maximum flooding surface of the sequence B3). This age coincides with the one determined in other northern Tethyan areas for the installation of the Urgonian platform. The results of this study show a strong tectonic control of the platform architecture, with the presence of syn-sedimentary faults in a perpendicular position to the progradation direction of the platform. The presence of these faults was highlighted by the study of the evolution of the microfacies distribution and by thickness variations in different areas. Sea level fluctuations also played an important role in the various life phases of the platform. Three major falls in sea level have been identified. A significant emersion of the proximal domain has been observed, involving an important drop of the relative sea level, leading to the exposure of the Drusberg Member hemipelagic series. A second major drop in sea level is identified near the Barremian-Aptian boundary, and a third is registered on the top of the Upper Schrattenkalk Member on the whole platform; it is associated with a karst affecting the underlying limestones to a depth of over 20 meters. This observation sheds new light on the conditions linked to the demise of Urgonian platform, which was strongly influenced by this phase of emersion.