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Background: The question of where to hospitalize extremely malnourished patients with anorexia nervosa (AN) is a real dilemma. On one hand, psychiatrists have to deal with severe medical complications that are not within their competences and that justify hospitalization in an internal medicine ward. On the other hand, medical doctors have to face psychic decompensations that would justify admission to a psychiatric ward. In this context, we share our experience of management of severely malnourished AN adult patients in a transdisciplinary specialized eating disorders (ED) unit, referral center for AN associated with somatic severity. Method: First, we described the modalities of care proposed to patients with AN hospitalized in the medical unit. Intensive medical care, both somatic and psychiatric, are provided thanks to a transdisciplinary therapeutic program, where objectives are to: medically stabilize the patient, initiate progressive refeeding and start supportive psychotherapy before being transferred to a psychiatric ED unit. Secondly, we conducted a retrospective descriptive study that included all adult patients with AN admitted for the first time to the unit, between November 1997 and January 2014, for severe malnutrition and/or complications of the ED. Objective was to specify patients’ characteristics: demographic, nutritional status, history of ED, care pathway. Results: Among a cohort of 386 adult patients with AN (21 males and 365 females) admitted for the first time in the unit, mean age was 29.4 (±11.5) years, mean BMI was 12.7 (±2.2) kg/m2. Before being supported in the unit, 78.2% of patients had already been hospitalized in other hospitals. Mean length of stay was 35.2 days. Patients were clinically serious and unstable because of life-threatening somatic complications due to a low BMI. During hospital stay, a temporary transfer to medical intensive care unit was necessary for 25.6% of patients. Average patient weight gain was 0.777 kg per week and 81.9% of patients benefited from enteral nutrition. Conclusion: This specialized transdisciplinary unit where physician nutritionists and psychiatrists coordinate medical care together, allow a better understanding and management of extreme malnutrition associated with AN. Thanks to their expertise, care teams are less critical and less rejecting towards patients. Thus, therapeutic alliance could be optimized.

BACKGROUND: Citrulline (CIT), is not extracted by the splanchnic area, can stimulate muscle protein synthesis and could potentially find clinical applications in conditions involving low amino acid (AA) intake, such as in malnourished older subjects. OBJECTIVE: Our purpose was to research the effects of CIT supplementation on protein metabolism in particular on non-oxidative leucine disposal (NOLD, primary endpoint), and splanchnic extraction of amino acids in malnourished older patients. DESIGN: This prospective randomized multicenter study determined whole-body and liver protein synthesis, splanchnic protein metabolism and appendicular skeletal muscle mass (ASMM) in 24 malnourished older patients [80-92 years; 18 women and 6 men] in inpatient rehabilitation units. All received an oral dose of 10 g of CIT or an equimolar mixture of six non-essential amino acids (NEAAs), as isonitrogenous placebo, for 3 weeks. RESULTS: NOLD and albumin fractional synthesis rates were not different between the NEAA and CIT groups. Splanchnic extraction of dietary amino acid tended to decrease (p = 0.09) in the CIT group (45.2%) compared with the NEAA group (60.3%). Total differences in AA and NEAA area under the curves between fed-state and postabsorptive-state were significantly higher in the CIT than in the NEAA group. There were no significant differences for body mass index, fat mass (FM), lean mass (LM) or ASMM in the whole population except for a tendential decrease in FM for the citrulline group (p = 0.089). Compared with Day 1, lean mass and ASMM significantly increased (respectively p = 0.016 and p = 0.018) at Day 20 in CIT-treated women (mean respective increase of 1.7 kg and 1.1 kg), and fat mass significantly decreased (p = 0.001) at Day 20 in CIT-group women (mean decrease of 1.3 kg). CONCLUSIONS: Our results demonstrate that CIT supplementation has no effect on whole-body protein synthesis or liver protein synthesis in malnourished older subjects. However, CIT supplementation was associated with a higher systemic AA availability. In the subgroup of women, CIT supplementation increased LM and ASMM, and decreased FM.

L'infection par le VIH est une maladie aux facettes multiples. Cette infection virale chronique est, au moins a ces debuts, pauci symptomatique. Elle detruit pourtant progressivement le systeme immunitaire tout en provoquant des perturbations metaboliques aux consequences inattendues. Celles-ci vont constituer le lit de la denutrition chronique dont l'installation plus ou moins rapide dependra des conditions d'environnement du sujet infecte, jusqu'au moment ou les infections dites opportunistes, en raison de leur survenue avec l'immunodepression, vont elles-memes precipiter et rendre irreversible cette denutrition. Le controle par les anti-retroviraux de la multiplication du virus va totalement bouleverser les voies metaboliques precedemment mises a mal. Ces nouvelles perturbations vont laisser une trace visible sur la silhouette du sujet infecte alors que le developpement de l'atherosclerose semble etre promu par cette nouvelle situation metabolique. Ces differentes facettes doivent etre connues. L'extension de l'epidemie de sida a travers le monde conduira tous les praticiens quelques soit leur specialite a la rencontrer. La denutrition au premier plan des aspects nutritionnels du sida depuis 20 ans ne disparait pas. Elle reste une preoccupation majeure des pays depourvus de possibilite therapeutique et n'a pas disparu des pays occidentaux favorises. Les aspects metaboliques et nouveaux que la survie des malades fait apparaitre mettra en demeure bien des medecins de pouvoir repondre aux questions des malades.

The relationship between birth weight and body composition at later stages in life was not studied previously in anorexia nervosa (AN). The aim of the following brief report is to present results concerning the relationship between birth weight and later body composition specifically in AN, and to check if the programming of body composition from birth weight is still detected in severely emaciated AN patients. One hundred and fifty-one female AN patients aged between 13 and 44 were recruited from 11 inpatient treatment facilities in France. Birth weight, body weight and height were obtained. Body composition was measured using bioelectrical impedance. Birth weight was significantly correlated to lifetime maximum body mass index (BMI; r=0.211, P=0.009) and significantly correlated to fat-free mass index (r=0.190, P=0.027) but not to fat mass index (FMI). This report confirms that even in AN when patients are severely emaciated and where fat-free mass (FFM) and fat mass (FM) are low, a link between birth weight and FFM and BMI can still be identified, independently from age. Further studies are needed on larger samples exploring other factors, such as gender, puberty and ethnicity.

The majority of patients with advanced cancer develop malnutrition. This malnutrition has an important impact on quality of life, performance status and immune status. It can be responsible for increased morbidity, particularly infectious complications and thus mortality. In five to more than 20% of patients with cancer, death can be directly related to cachexia in the terminal phase (Inagaki et al, 1974; Bozzetti, 1995).

The purpose of this study was to estimate the prevalence of malnutrition in outpatients on long-term oxygen therapy or home mechanical ventilation, to determine the relationships between malnutrition and impairment/disability and smoking and also to identify relevant tools for routine nutritional assessment. In 744 patients (M:F 1.68, aged 65+/-15 yrs) with chronic obstructive pulmonary disease (COPD, 40%), restrictive disorders (27%), mixed respiratory failure (15%), neuromuscular diseases (13%) and bronchiectasis (5%), body mass index (BMI), fat-free mass (FFM), serum albumin, transthyretin, 6-min walking test, forced vital capacity (FVC), forced expiratory volume in one second (FEV1) and blood gases were recorded. FFM was the most sensitive parameter for detecting malnutrition, being abnormal in 53.6% of patients, while BMI was

Highly-active antiretroviral therapy (HAART) has lead to a dramatic decrease in the morbidity of patients infected with the human immunodeficiency virus (HIV). However, metabolic side effects, including lipodystrophy-associated (LD-associated) dyslipidemia, have been reported in patients treated with antiretroviral therapy. This study was designed to determine whether successful HAART was responsible for a dysregulation in the homeostasis of tumor necrosis factor-alpha (TNF-alpha), a cytokine involved in lipid metabolism. Cytokine production was assessed at the single cell level by flow cytometry after a short-term stimulation of peripheral blood T cells from HIV-infected (HIV(+)) patients who were followed during 18 months of HAART. A dramatic polarization to TNF-alpha synthesis of both CD4 and CD8 T cells was observed in all patients. Because it was previously shown that TNF-alpha synthesis by T cells was highly controlled by apoptosis, concomitant synthesis of TNF-alpha and priming for apoptosis were also analyzed. The accumulation of T cells primed for TNF-alpha synthesis is related to their escape from activation-induced apoptosis, partly due to the cosynthesis of interleukin-2 (IL-2) and TNF-alpha. Interestingly, we observed that LD is associated with a more dramatic TNF-alpha dysregulation, and positive correlations were found between the absolute number of TNF-alpha CD8 T-cell precursors and lipid parameters usually altered in LD including cholesterol, triglycerides, and the atherogenic ratio apolipoprotein B (apoB)/apoA1. Observations from the study indicate that HAART dysregulates homeostasis of TNF-alpha synthesis and suggest that this proinflammatory response induced by efficient antiretroviral therapy is a risk factor of LD development in HIV(+) patients.

SUMMARY 1 Sixty children with febrile convulsions under the age of 3 were maintained on prophylactic phenobarbital in a dose of 3–4 mg/kg given in divided dosage twice daily. Double the ordinary dose was given for the first 2 days to achieve a therapeutic serum concentration within a few days. The serum concentration was checked before discharge from the hospital and at intervals of 1–3 months for 6 months. 2 Among 27 children with a serum concentration habitually at or over 16 mg/1, 1 had a brief febrile convulsion within 6 months (serum concentration not determined at the time of the convulsion). When the serum concentration was habitually or at the time of the convulsion at or under 15 mg/1, the incidence of recurrences was the same as in an untreated group, 21 % within 6 months. 3 It did not prove difficult to persuade the mothers to give the medication faithfully. There were few complications: hypersensitive rash in 1, emotional instability in 1 and acute intoxication in 2. If a few simple precautions are observed, prophylactic medication with phenobarbital is harmless and is effective in preventing recurrences. RESUME 1 Soixante enfants, âges sous 3 ans et ayant des convulsions febriles, ont ete maintenus a un traitement prophylactique, avec du phenobarbital a des doses de 3–4 mg/kg par jour. Pendant les 2 premiers jours, on a donne le double de la dose habituelle pour obtenir en quelques jours une concentration therapeutique dans le serum. Les concentrations seriques ont ete controlees apres l'admission a l'hopital et a des intervalles de un a trois mois pendant une periode de 6 mois. 2 Chez les sujets dont la concentration serique habituelle ou au moment des convulsions etait inferieure a 15 mg/1, les crises se sont reproduites avec un pourcentage identique a celui d'un groupe non-traite, c'est-a-dire 21 % au cours d'une periode d'observation de 6 mois. Par contre, chez 27 enfants qui avaient une concentration serique habituelle egale ou superieure a 16 mg/1, 1 seulement a presente une convulsion febrile de breve duree en 6 mois (au moment de la convulsion, on n'a pas determine la concentration serique). 3 Il s'est avere qu'il n'est pas difficile de persuader les meres de donner le traitement de facon adequate. II y a eu peu de complications: un rash hyper-sensitif dans 1 cas, une instabiliteemotive dans un cas et une intoxication aigue dans 2 cas. Si on prend quelques precautions simples, le traitement prophylactique par phenobarbital est sans danger et efficace pour prevenir la reapparition des crises.

SUMMARY 1 A well-controlled trial of prophylactic medication with diphenylhydantoin showed it to be ineffective in preventing febrile convulsions in children under 3 years of age. Twenty-three children were followed for 6 to 30 months. The serum concentration of diphenylhydantoin was determined every 2–3 months and was consistently above 10 μg/ml. The recurrence rate was slightly higher in them than to be expected in untreated children. Consideration was taken of the relation of age, sex and family history to the rate of recurrence. The serum concentration of the drug at the time of 5 febrile convulsions was in and above the therapeutic range in adults. 2 It is possible that diphenylhydantoin (

Changes in minute ventilation, tracheal airway pressure and lung volume have been measured using a jet ventilator (VS 600) during different rates of ventilation, I:E ratios and driving pressures. A lung model with a slightly increased compliance and an increased airway resistance was used. Five rates of ventilation (from 60 to 230 b.p.m.), three I:E ratios (0.25, 0.43, 0.67) and three driving pressures (200, 300 and 400 kPa) were studied. The increases in the rate of ventilation did not modify minute ventilation significantly, decreased peak airway pressure only slightly and increased end-expiratory pressure and lung volume. The increases in I:E ratio produced increases in minute ventilation, peak airway pressure, end-expiratory pressure and lung volume. The increases in driving pressure induced changes similar to those produced by the alterations in I:E ratio.

113 cases of infantile spasms were diagnosed in the period 1 April 1970 to 31 March 1975 after Denmark changed her immunization programme. Previously whooping cough vaccine was given as the triple combination at 5, 6, and 15 months of age. From 1 April 1970 it was given as a monovalent vaccine at 5 and 9 weeks of age and at 10 months of age. A comparison with previous material of 86 cases of infantile spasms from 1957 to 1967 showed no change in the age at onset. Though there may be an occasional connection between immunization and infantile spasms, the most important factor is a time-coincidence between any immunization given at a certain age with the neurological disorders which are natural for that age.

The haemodynamic responses to induction and tracheal intubation have been studied in patients with coronary artery disease randomly assigned to a labetalol pretreatment group (n = 14) or to a placebo group (n = 16). Twelve hour before operation, treated patients received a bolus dose of labetalol 0.5 mg kg-1 followed by a constant infusion of 0.1 mg kg-1 h-1 i.v. Anaesthesia was induced with thiopentone and phenoperidine, and intubation performed following the administration of suxamethonium. At intubation, the changes in heart rate (P less than 0.01), mean arterial pressure (P less than 0.05) and rate-pressure product (P less than 0.01) were significantly smaller in the labetalol group compared with the placebo group. Labetalol pretreatment appears satisfactory and may be useful in patients with coronary artery disease who have a normal left ventricular ejection fraction.

On pneumoencephalograms (PEG) of children, assessed as normal, the Evans[See figure in the PDF file]ratio proved to be independent of age, while the septum caudate (S-C) distance showed a slight increase. In assessing the size of the lateral ventricles of children we, therefore, prefer using Evans' ratio.Our knowledge of normal ventricular size in infants under 1 year of age has proved insufficient.Whether the position of the head during the exposure influences the value of the septum caudate distance is discussed.

Anorexia and cachexia are serious complications frequently found in patients with cancer (Bozetti, 1995; Donnelly and Walsh, 1995). They are present in about 10% of patients at the time of diagnosis (Bozetti et al, 1989). Multiple factors are involved in their aetiology (Puccio and Nathanson, 1997). The resultant malnutrition is associated with a poorer response to anticancer treatment and an impaired quality of life (Holmes and Dickerson, 1987; Bozetti, 1995; De Conno et al, 1998). Many clinical trials have been undertaken to evaluate the efficacy of drugs thought to be appetite stimulants.