Development and current use of parenteral nutrition in critical care - an opinion paper.

Critically ill patients depend on artificial nutrition for the maintenance of their metabolic functions and lean body mass, as well as for limiting underfeeding-related complications. Current guidelines recommend enteral nutrition (EN), possibly within the first 48 hours, as the best way to provide the nutrients and prevent infections. EN may be difficult to realize or may be contraindicated in some patients, such as those presenting anatomic intestinal continuity problems or splanchnic ischemia. A series of contradictory trials regarding the best route and timing for feeding have left the medical community with great uncertainty regarding the place of parenteral nutrition (PN) in critically ill patients. Many of the deleterious effects attributed to PN result from inadequate indications, or from overfeeding. The latter is due firstly to the easier delivery of nutrients by PN compared with EN increasing the risk of overfeeding, and secondly to the use of approximate energy targets, generally based on predictive equations: these equations are static and inaccurate in about 70% of patients. Such high uncertainty about requirements compromises attempts at conducting nutrition trials without indirect calorimetry support because the results cannot be trusted; indeed, both underfeeding and overfeeding are equally deleterious. An individualized therapy is required. A pragmatic approach to feeding is proposed: at first to attempt EN whenever and as early as possible, then to use indirect calorimetry if available, and to monitor delivery and response to feeding, and finally to consider the option of combining EN with PN in case of insufficient EN from day 4 onwards.

Pragmatic approach to nutrition in the ICU: Expert opinion regarding which calorie protein target.

BACKGROUND & AIMS: Since the publications of the ESPEN guidelines on enteral and parenteral nutrition in ICU, numerous studies have added information to assist the nutritional management of critically ill patients regarding the recognition of the right population to feed, the energy-protein targeting, the route and the timing to start. METHODS: We reviewed and discussed the literature related to nutrition in the ICU from 2006 until October 2013. RESULTS: To identify safe, minimal and maximal amounts for the different nutrients and at the different stages of the acute illness is necessary. These amounts might be specific for different phases in the time course of the patient's illness. The best approach is to target the energy goal defined by indirect calorimetry. High protein intake (1.5 g/kg/d) is recommended during the early phase of the ICU stay, regardless of the simultaneous calorie intake. This recommendation can reduce catabolism. Later on, high protein intake remains recommended, likely combined with a sufficient amount of energy to avoid proteolysis. CONCLUSIONS: Pragmatic recommendations are proposed to practically optimize nutritional therapy based on recent publications. However, on some issues, there is insufficient evidence to make expert recommendations.

Victimization in Childhood of Male Sex Offenders: Relationship between Violence Experienced and Subsequent Offenses through Discourse Analysis

This study aims at better understanding how the form of childhood violence experienced and the type of offense subsequently committed affect how sex offenders recall punishments and difficult events. Fifty-four male perpetrators convicted of sexual offenses against children (SOCs) or against adults (SOAs) were interviewed in France, Belgium, and Switzerland using the Lausanne Clinical Interview (Entretien Clinique de Lausanne or LCI). Almost three-quarters of the sex offenders reported having been victimized during childhood. The correspondence analysis identified several factors that differentiated them. Their appraisal of the distressing event, method of coping with and distancing themselves from it, and how they dealt with emotions varied markedly depending on whether they recognized having experienced various forms of violence during childhood and on what type of offense they subsequently committed. Victimization can be identified as much by the events experienced as by their effect on the sex offender's discourse. Identification of these discursive indicators may lead to an improved therapeutic approach for potentially traumatic childhood experiences.

Patients' spontaneous discourse on the importance of significant others in the course of transplantation: A qualitative study

Background: This study explores significant ones' implication before and after transplantation. Methods: Longitudinal semi-structured interviews were conducted in 64 patients awaiting all-organ transplantation. Among them, 58 patients spontaneously discussed the importance of their significant other in their daily support. Discourse analysis was applied. Findings: During the pre-transplantation period renal patients reported that significant others took part in dialysis treatment and participated to regimen adherence. After transplantation, quality of life improved and the couple dynamics returned to normal. Patients awaiting lung or heart transplantation were more heavily impaired. Significant others had to take over abandoned roles. After transplantation resuming normal life became gradually possible, but after one year either transplantation health benefits relieved physical, emotional and social loads, or complications maintained the level of stress on significant others. Discussion: Patients reported that significant others had to take over various responsibilities and were concerned about long-term stress that should be adequately supported.

The category 'natural' in the discourse of couples who used medically assisted procreation

As a constantly evolving set of complex biotechnologies, medically assisted procreation (MAP) jeopardises a category that seems to be taken for granted: that of 'natural'. What is 'natural' or not when MAP is used to procreate? What are the boundaries between a 'natural' and a 'non-natural' fertilisation? Drawing upon a dialogical approach to language and cognition, our study examined the semantic field of the category 'natural' as expressed in interviews between a psychiatrist and seven couples who resorted to MAP and had to decide whether to keep their frozen pre-embryonic cells (zygotes) for further procreation or to allow them be destroyed. We examined how these couples evoked the category 'natural' and showed that in their argumentation, the category 'natural' encompassed a wide variety of phenomena, which shifted the boundaries between the 'natural' and 'non-natural'. In so doing, the couples 'renaturalised' MAP, normalized it, moved the boundaries between what is legitimate or not, and showed their accountability. Hence, reference to the category 'natural' seemed to act both as an argumentative and a psychological resource in the elaboration of the person's experience in resorting to MAP.

Qualité des soins ambulatoires : opinion des patients infectés par le VIH

Ce travail décrit une étude, qui a visé à évaluer la performance d'un questionnaire de satisfaction en développement, destiné à mesurer l'opinion de patients infectés par le VIH suivis ambulatoirement. 1. Problématique. 1.1. La qualité des soins, une définition. 1.2. L'opinion des patients : comment la mesurer ? Le questionnaire, les questionnaires existants, le focus groups, description de la technique. 2. Patients et méthodes. 2.1. Critères d'inclusion et d'exclusion. 2.2. Les envois et les rappels. 2.3. Stabilité test-retest. 2.4. Le recrutement. 3. Résultats. 3.1. Acceptabilité du questionnaire : participation. 3.2. Représentativité de l'échantillon. 3.3. Scores par dimension. 3. 4. Evaluation de la validité du questionnaire, convergence des items par dimension et cohérence interne. 3.5. Les questions issues du questionnaire SF-36. 4. Discussion. 4.1. Coping et méthodes alternatives. 4.2. Impact sur les service d'une enquête sur la qualité des soins. 5.1. Le questionnaire de satisfaction élaboré. 5.2. Les différents questionnaires des Hospices : patients hospitalisés et ambulatoires. 5.3. Formulaire d'information de l'enquête par questionnaire. 5.4. Formulaire de consentement à l'enquête. 5.5. Lettre d'accompagnement du questionnaire. 5.6. Profil socio-démographique et résultats complets par item.