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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.

Introduction et but de l’etude L’anorexie mentale (AM) est la pathologie psychiatrique avec le plus haut taux de mortalite, notamment a cause de la denutrition. L’immunodepression cellulaire induite par cette denutrition severe pourrait etre a l’origine de l’apparition d’infections pulmonaires chroniques opportunistes (IPCO). Seuls quelques cas d’IPCO dans l’AM ont ete rapportes dans la litterature. Le but de cette etude etait d’identifier les facteurs associes aux IPCO dans une population de patients denutris atteints d’AM. Materiel et methodes Une etude observationnelle a ete realisee dans un service soins tertiaires dedie aux patients atteints d’AM et severement denutris. Le diagnostic d’IPCO a ete fait sur la presence de lesions suggestives au scanner thoracique, associe ou non a une identification microbiologique. Chaque patient avec un diagnostic d’IPCO a ete apparie sur l’âge et le sexe a deux patients non malades, hospitalises au cours de la meme periode. Les variables suivantes ont ete recueillies : poids, IMC, CRP, albuminemie, transthyretine, neutrophiles, lymphocytes, et identification des germes a la culture des expectorations le cas echeant. Le test t de Student et la regression logistique ont ete effectues pour determiner les parametres associes aux IPCO. Une analyse discriminante et des courbes de ROC ont ete realisees pour les variables significatives en univariee. Resultats et analyse statistique Entre 2004 et 2020, 1441 patients ont ete hospitalises et 31 avaient un diagnostic d’IPCO (2,2 %). Les patients atteints d’IPCO avaient un IMC inferieur (11,5 vs 13,0 ; p = 0,02), un taux de lymphocytes sanguins plus bas (763 vs 1637/mm3 ; p Conclusion L’IPCO est une des complications somatiques observees chez les patients avec AM. Cette etude observationnelle a identifie le taux de lymphocytes comme etant le principal facteur predictif d’IPCO. Des etudes prospectives sont necessaires pour confirmer ce seuil en prospectif et juger de l’utilite de realiser un scanner thoracique systematique pour ces patients.

Background The need to preserve operating room (OR) scheduling flexibility can challenge adherence to the 2-h pre-operative fasting period recommendation before elective surgery. Our primary objective was to assess the feasibility of a pre-operative carbohydrate (CHO) drink delivery strategy preserving OR scheduling flexibility. Methods During the 1st study phase, patients admitted for elective surgery fasted overnight (Control group); during the 2nd phase, patients fasted overnight and received a pre-operative CHO drink (CHO group). CHO delivery time was set to allow any patient to be ready for surgery 30 min ahead of the scheduled time and any patient with an operation scheduled in the afternoon to be ready at 13:00 hours; patients admitted the morning of an early morning operation would not be allowed to take a CHO drink. Results We included 194 patients in the Control group and 199 in the CHO group. In the CHO group, the morning CHO dose was delivered to 66.3% of the patients (95% CI 59.3–72.9%), with a median pre-operative fasting time period of 4 h 57 min. After excluding patients admitted the morning of an operation scheduled before 10:00 hours, the delivery rate was 77.2% (70.2–83.3%). Patients in the CHO group experienced significantly less pre-operative thirst (median 2 vs. 5 on a 0–10 scale, P < 0.0001) and hunger (0 vs. 2, P < 0.0001) than those in the Control group. Conclusion Although preservation of OR scheduling flexibility resulted in a longer fasting time than recommended, CHO drink can be made available to a large proportion of patients with significantly reduced perioperative discomfort.

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.

Patients with the DMC syndrome have been suggested to possess a specific sulfatase abnormality and/or to be deficient in a proteinase cleaving glycoprotein-acid mucopolysaccharide (AMP) linkage. We have previously found in DMC patients an abnormal excretion of urinary AMPs of which hyaluronic acid and chondroitin sulfate (A + C) were oversulfated and keratosulfate and heparan sulfate were undersulfated. Lysosomal acid proteinase, i.e. cathepsin D (EC 3.4.23.5) and neutral proteinase : elastase (EC 3.4.21.11) and cathepsin G were found to be normal in DMC patients. However, alpha 2-macroglobulin in serum was raised. This increase may be associated with a complex formation of alpha 2-macroglobulin with a neutral proteinase released from the cells. Increased levels of chondroitin sulfate N-acetylgalactosamine-6-sulfate sulfatase and sulfamidase and decreased enzymic levels of arylsulfatase A and B (EC 3.1.6.1) were found in leucocytes of DMC patients. The sulfatase activities assayed in the present study support our theory that a specific sulfatase abnormality may exist in the DMC syndrome.

Introduction et but de l’etude Le vieillissement est associe a la sarcopenie qui peut etre aggravee par la denutrition. Il a ete demontre que la citrulline (Cit) a la propriete de stimuler la synthese proteique musculaire et de diminuer la masse grasse chez le rat âge. Notre hypothese est que la Cit pourrait stimuler la synthese proteique musculaire et augmenter la masse musculaire chez la personne âgee denutrie, qui presente une resistance a l’anabolisme musculaire. Materiel et methodes Cette etude prospective, randomisee, multicentrique a inclus 29 patients âges denutris hospitalises en soins de suite. Ils recevaient, pendant 20 j, par voie orale, soit 10 g de Cit, soit un melange equimolaire de six acides amines non essentiels (AANE) comme placebo isoazote. La composition corporelle des patients etait evaluee par DEXA a j1 et a j20 : masse maigre totale (MM), masse maigre squelettique appendiculaire (MMSA), masse grasse (MG). Resultats Vingt-quatre patients ont termine l’etude. Les MM et MMSA etaient significativement augmentees a j20 par rapport a j1 dans le groupe Cit. La MG etait significativement diminuee dans le groupe Cit chez les femmes. Les variations de la MMSA et de la MG etaient significativement differentes entre les deux groupes chez les femmes ( Tableau 1 ). Conclusion Cette etude demontre pour la premiere fois que la Cit augmente la masse maigre et reduit la masse grasse chez des patients âges denutris hospitalises.

Resume L’existence d’une denutrition liee a la maladie parmi les patients sejournant dans les hopitaux europeens est incontestable. En 1999, le Conseil de l’Europe a decide de reunir les experts nationaux de 12 pays dans le cadre des « accords partiels dans le domaine social et de la sante publique ». Le but etait de faire un etat des lieux en matiere de soins nutritionnels dans les hopitaux et de proposer des actions d’amelioration de ceux-ci. Cinq points majeurs de disfonctionnement ont ete retenus : 1) absence de responsabilites clairement definies ; 2) insuffisance de formation en nutrition, toutes categories de personnels confondues ; 3) absence d’influence et ignorance des patients ; 4) absence de cooperation entre les differentes categories de personnels ; 5) absence d’implication des administrateurs d’hopital. Pour resoudre cette problematique difficile, une collaboration multidisciplinaire est indispensable, incluant tous les professionnels impliques a un quelconque niveau dans la restauration hospitaliere et l’alimentation des malades, y compris les personnels soignants.

Introduction et but de l’etude La prise en charge nutritionnelle de la sarcopenie et de la denutrition est souvent peu efficace chez la personne âgee, notamment a cause de la resistance a l’anabolisme proteique postprandial. La citrulline stimule la synthese proteique musculaire chez le rat âge et chez l’homme jeune. Le but de cette etude etait de mesurer si la citrulline est efficace sur le turn over proteique des patients âges denutris hospitalises. Materiel et methodes Cette etude prospective (PHRC national de 2007, ClinicalTrials.gov Identifier : NCT00714675 ), randomisee et multicentrique a inclus 29 patients âges denutris hospitalises en soins de suite geriatrique. Ils recevaient tous, pendant 20 jours, par voie orale, soit 10 g de citrulline soit un melange iso-azote de 6 acides amines non essentiels. Le turn over proteique corps entier, la vitesse de synthese fractionnaire de l’albumine et la sequestration splanchnique ont ete mesures le 21e jour par une technique de dilution isotopique utilisant la (13C)-leucine et la 3D-leucine, chez des patients a jeun depuis 12 h et en situation postprandiale. Resultats Vingt-quatre patients ont termine l’etude. Il n’y a pas de modification du turn over proteique et de la synthese proteique corps entier (NOLD). La vitesse de synthese fractionnaire de l’albumine n’etait pas modifiee. En revanche, il existait une tendance a la diminution de l’extraction splanchnique des acides amines chez les patients traites par la citrulline (citrulline : 45,2 [26,2 ; 58,4] %/j, acides amines non essentiels : 60,3 [48,3 ; 69,7 %/j] p Conclusion Cette etude montre que la citrulline n’a d’effet ni sur la synthese proteique corps entier ni sur la vitesse de synthese fractionnaire de l’albumine. En revanche, elle tend a diminuer la sequestration splanchnique des acides amines et augmente leur biodisponibilite en peripherie. Ce processus etant une des cles de la synthese proteique, la citrulline pourrait etre un adjuvant nutritionnel interessant, en presence d’une prise en charge hypercalorique–hyperproteique, chez les personnes âgees denutries.

ResumenEste trabajo era un estudio metabólico de la bulimia nerviosa necesario para diseñar una terapia cognitivoconductual (TCC) a corto plazo que comenzaba con una admisión breve en una sala psiquiátrica. El tratamiento produjo mejorías significativas en la conducta alimentaria, y los resultados se comparan con los de estudios publicados antes. Las comparaciones no indican que una admisión breve al comienzo de la terapia pueda aumentar su efectividad. Por otro lado, se encontró que el aumento en la ingesta normal de alimentos correlacionaba significativamente con la disminución en los atracones. Esto apoya la noción de que la ingesta apropiada de alimentos a la hora de las comidas debería ser una cuestión importante en la TCC para la bulimia nerviosa.

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.

Weight loss is reported by more than 20% of hepatitis C virus (HCV)-monoinfected patients treated with the peg-interferon (peg-IFN) and ribavirin combination. The aim of this study was to determine the incidence and risk factors of severe weight loss (> or =10%) in human immunodeficiency virus (HIV) / HCV-coinfected patients participating in a randomized, controlled 48-week trial comparing peg-IFN alpha 2b plus ribavirin with IFN alpha-2b plus ribavirin. Univariate and multivariate analyses were used to identify links with antiretroviral treatments, anti-HCV therapy and clinical and laboratory findings. One hundred eleven (28.9%) of 383 patients who received at least one dose of anti-HCV treatment subsequently had severe weight loss. Among patients who took at least 80% of the planned total dose, severe weight loss occurred in 74 patients (32.7%). In multivariate analysis, age >40 years [hazard ratio (HR), 1.59; 95% CI 1.09 to 2.31; P = 0.016], body mass index (BMI) >22 (HR, 1.72; 95% CI, 1.16 to 2.55; P = 0.0069), peg-IFN alpha-2b (HR, 1.82; 95% CI, 1.24 to 2.69; P = 0.0022) and female sex (HR, 1.60; 95% CI, 1.05 to 2.43; P = 0.027) were associated with severe weight loss. In contrast, patients taking non-nucleoside reverse transcriptase inhibitors (NNRTI)-containing antiretroviral regimens were less likely to lose weight (HR, 0.62; 95% CI, 0.39 to 0.96; P = 0.034). Lipodystrophy tended to occur more frequently in patients who had severe weight loss than in the other patients (26.1%vs 17.6%; P = 0.0682) and patients whose weight loss >5% persisted 24 weeks after the completion of anti-HCV therapy (n = 58 / 111) were more likely to be receiving stavudine-based antiretroviral therapy, suggesting that mitochondrial toxicity plays some role in weight loss. These findings show that severe weight loss is a frequent side effect of anti-HCV therapy in HIV / HCV-coinfected patients. The underlying mechanisms remain to be identified.

Le syndrome de renutrition ou plus exactement syndrome de renutrition inapproprie (SRI) regroupe tous les symptomes cliniques et les perturbations metaboliques qui surviennent au debut et en cours de renutrition chez des patients prealablement denutris chroniques ou ayant subi un jeune prolonge. Le terme de refeeding syndrome (RS) apparait dans la litterature dans les annees 1970, aux premices de la nutrition parenterale (1). Toutefois, les risques ďune renutrition inappropriee sont connus de longue date et ne sont donc pas ľapanage de la nutrition parenterale. Si les risques de la denutrition, et plus specifiquement le risque vital, sont bien connus, les risques de la renutrition le sont moins. Les consequences peuvent en etre dramatiques et conduire a un syndrome de defaillance multiviscerale voire au deces (2). Il est donc utile de bien connaitre les aspects physiopathologiques de ce syndrome et les situations a risque de survenue, pour tenter de le prevenir au maximum et de savoir le prendre en charge des le debut des signes annonciateurs pour en eviter le risque evolutif parfois catastrophique.

La denutrition est ľun des problemes majeurs de sante publique de la planete. Plus frequent te aux âges extremes de la vie ou son evaluation est souvent difficile, elle touche, a titre ďexemple, cent millions ďenfants dans le monde. Elle n’est pas ľapanage du tiers-monde; elle touche souvent les populations âgees et defavorisees sur le plan social, et egalement les malades hospitalises. Dans ce dernier cas, elle s’installe sournoisement, reste souvent ignoree, et augmente la morbidite et la mortalite (1, 2, 3, 4, 5). Maigreur, denutrition, malnutrition sont des termes souvent confondus pour designer des situations pathologiques differentes. Quelques definitions sont donc necessaires. Le terme de maigreur designe un etat clinique caracterise par un poids en dessous ďune valeur moyenne habituellement observee, mais ne signifie pas forcement que cet etat soit pathologique. Il peut en effet s’agir ďun etat constitutionnel. La malnutrition est un terme anglais qui signifie que les apports alimentaires ne sont pas equilibres, designant aussi bien une sous-alimentation par carence qu’une suralimentation par exces.

To characterize intra-abdominal adipose tissue changes in HIV patients with clinical lipodystrophy using a reproducible imaging technique. Materials and methods. 89 HIV patients with clinical lipodystrophy were included. A single axial T1W image was acquired at the mid L4 vertebral level. Two radiologists measured subcutaneous (SAT) and visceral (VAT) adipose tissues using a semi-automated method. Measurements were compared to a matched population (race, sex, age and BMI).Measurements of abdominal adipose tissue on MRI are reproducible. Three clinical types of lipodystrophy are described in males with increased visceral (VAT) and reduced subcutaneous (SAT) adipose tissues compared to control subjects. Two clinical types of lipodystrophy are described in females with increased visceral (VAT) and unchanged subcutaneous (SAT) adipose tissues.MRI with comparison between HIV patients and normal control subjects is a reproducible method to characterize adipose tissue changes of lipodystrophy and evaluate its severity. Evaluation of a adipose tissue distribution in a large control population would be helpful to the study of metabolic disorders.

Undernutrition (wasting) is still frequent in patients infected with the human immunodeficiency virus (HIV), despite recent decreases in the prevalence of undernutrition in western countries (as opposed to developing countries) due to the use of highly active antiretroviral treatment. Undernutrition has been shown to have a negative prognostic effect independently of immunodeficiency and viral load. These guidelines are intended to give evidence-based recommendations for the use of enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) in HIV-infected patients. They were developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. Nutritional therapy is indicated when significant weight loss (>5% in 3 months) or a significant loss of body cell mass (>5% in 3 months) has occurred, and should be considered when the body mass index (BMI) is

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).

We have previously shown that lipid alterations in HIV-1-associated lipodystrophy (LD) are correlated with decreased serum dehydroepiandosterone (DHEA) and increased cortisol:DHEA ratio and IFN-alpha levels.To evaluate in a longitudinal study whether steroid and cytokine modifications are associated with the evolution of physical changes and lipid alterations associated with LD.Thirty-four HIV-1-positive men were followed during 32.5 +/- 4.0 months and tested at four time-points. The patients were subdivided into five groups according to physical changes and anthropometric measurements: LD-negative, initially LD-negative becoming LD-positive, LD-positive unchanged, aggravated or improved. Serum lipids, apolipoproteins, adrenal steroids and cytokines were measured and compared with baseline values.(1) LD aggravation is associated with persistent elevated lipids, a decrease in serum DHEA, an increase in cortisol:DHEA ratio and persistent high levels of IFN-alpha. (2) LD improvement is associated with normalization of serum lipids, an increase in serum DHEA leading to normalization in cortisol:DHEA ratio, and normalization of IFN-alpha levels. (3) In LD-positive men evolution of VLDL cholesterol is negatively correlated with DHEA (r = -0.56, P0.01) and positively with cortisol:DHEA ratio (r = 0.62, P0.004) and with IFN-alpha (r = 0.57, P0.01). (4) The switch to LD is associated with a decrease in serum DHEA. (5) Patients who remained LD-negative maintained normal lipids, elevated cortisol and DHEA, and normal cortisol:DHEA ratio and normal levels of IFN-alpha.This study indicates that cortisol:DHEA ratio and serum IFN-alpha levels are closely associated with clinical evolution and atherogenic lipid alterations in LD.

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

In 1999 the Council of Europe decided to collect information regarding Nutrition programmes in hospitals and for this purpose a network consisting of national experts from eight of the Partial Agreement member states was established. The aim was to review the current practice in Europe regarding hospital food provision, to highlight deficiencies and to issue guidelines to improve the nutritional care and support of hospitalized patients. Five major problems seemed to be common in this context: 1) lack of clearly defined responsibilities; 2) lack of sufficient education; 3) lack of influence of the patients; 4) lack of co-operation among all staff groups; and 5) lack of involvement from the hospital management. To solve the problems highlighted, a combined 'team-effort' is needed from national authorities and all staff involved in the nutritional care and support, including hospital managers.

The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of the French Cancer Centres (FNCLCC), the 20 French Cancer Centres and specialists from French Public Universities, General Hospitals and Private Clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and outcome for cancer patients. The methodology is based on literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery.To develop clinical practice guidelines according to the definitions of the Standards, Options and Recommendations project for home parenteral or enteral nutrition in adult cancer patients.Data were identified by searching Medline, Cancerlit, web sites and using the personal reference lists of members of the expert groups. Once the guidelines were defined, the document was submitted for review to 72 independent reviewers.The main recommendations for home parenteral or enteral nutrition in adult cancer patients are: 1) Home parenteral or enteral nutrition concerns cancer patients with malnutrition or with inadequate/impossible oral intake, during therapy of because of therapeutic after-effects (standard). Same indications apply for home and hospital artificial nutrition (standard). 2) Patients need a multidisciplinary follow-up (oncologists, nutritionists, and pain specialists), and this follow-up will make treatment adaptations according to the nutritional status possible (recommendation, expert agreement). An active participation of patients and/or their family circle is very important (standard). 3) The benefit of home parenteral or enteral nutrition on the quality of life of terminally ill patients (vs. hydration) has not been demonstrated. When life expectancy is below 3 months, and the Karnofsky index below 50, the drawbacks of home artificial nutrition are more important than its advantages. In this case, home parenteral or enteral nutrition is not recommended (recommendation, expert agreement). 4) Prospective clinical trials are recommended to evaluate the impact of home nutrition on quality of life in cancer patients (expert agreement). 5) The use of educational booklets that mention the telephone number of a referent health care and what to do when a problem happens (e.g. fever on home parenteral nutrition) is recommended (expert agreement). In France, patients should be referred to authorized home parenteral nutrition centres (recommendation, expert agreement).

Ritonavir (RTV) is a powerful inhibitor of P450 3A4 cytochorme. When given in combination with indinavir (IDV) it increases the IDV trough concentrations (Cmin) allowing a lower IDV dosage in a twice a day regimen, independently of meals. We report tolerance data and IDV Cmin levels observed in plasma and cerebrospinal fluid (CSF) in a cohort of HIV-infected patients treated with the IDV-RTV combination at different dosages of IDV and RTV.IDV Cmin was assayed 56 times in 40 patients (few patients had received different dosages of the IDV-RTV combination). Tolerance was recorded.For patients given the IDV-RTV combination at the doses of 800/100 mg b.i.d., 800/200 mg b.i.d. or 400/400 mg b.i.d., the IDV Cmin was 12 times the median IDV IC95. If the Cmin/IC95 ratio was greater than 10 with the 800/100 mg b.i.d. regimen and virological success was achieved, the IDV dosage was reduced to 400 mg b.i.d. For these patients, the 400/100 mg b.i.d. IDV-RTV regimen always gave a Cmin above the IDV IC95. Median Cmin for IDV in CSF was 146 ng/ml (range 71-881 ng/ml), above the IDV IC95. It was possible to control most of the adverse effects by reducing dosage after obtaining the IDV pharmacological levels. Definitive interruption of treatment was required in only 2 cases at mean follow-up of 7.9 months.The IDV-RTV combination should be used to improve observance of antiretroviral treatments and reduce the risk of virological failure related to low plasma levels. The IDV-RTV combination at 800/100 mg b.i.d. is a useful protocol when IDV efficacy alone is the goal. The 400/400 mg b.i.d. IDV-RTV regimen is an interesting alternative when efficacy of both inhibitors is the goal. Drug assays should be systematic to adapt individual dosages and limit the risk of adverse effects.

The August 1997 Directive of the Direction of General Health in France extended indications for antiretroviral treatment to risk of HIV exposure by sexual intercourse or syringe sharing. In November 1997, in collaboration with the Hauts-de-Seine MedicoJudiciary center, the Infectious Disease unit of the Raymond Poincaré Garches Hospital established a health care and anti-HIV prophylaxis clinic for victims of sexual assault. We report here the experience in 1998 and 1999.Between January 1998 and December 1999, 109 victims of sexual assault, 105 women and 4 men, mean age 24.7 +/- 10.6 years attended the clinic.Mean delay from assault to antiretroviral tritherapy (AZT, 3TC, indinavir) was 18.35 +/- 17.39 hours. Mean duration of antiretroviral treatment was 17.4 +/- 11.8 days. HIV screening in perpetrators enabled early interruption of the antiretroviral treatment in 23 cases (21.1%). Sixty-two victims (62%) were still in follow-up at W4/W7. Excellent compliance to tritherapy was observed in these subjects. Clinical intolerance was observed in 46.6% with nausea-vomiting in 91.4% of the cases. Adverse effects led to interruption of indinavir in 5 cases. Initial HIV serology was negative in all cases and no case of HIV seroconversion was observed. Among the 23 known perpetrators, one was HIV-positive with an HIV-RNA at 88,000 copies. Sixty-one victims (55.9%) had been previously vaccinated against the hepatitis B virus; 16 victims were vaccinated after the assault. There were no cases of hepatitis B virus seroconversion. Search for chlamydiae in vaginal secretions was positive in 3 cases and chlamydia serology demonstrated a seroconversion in 1 case. There was no case of syphylitic seroconversion and no case of gonococcal or trichomonas infection.The low rate of attendance for follow-up in regards to the gravity of the potential risk of HIV and/or hepatitis B virus transmission and the burden and cost of the antiretroviral treatment highlight the need for better medico-psycho-social support for rape victims. For the victims who attended the clinic, antiretroviral treatment was generally well accepted and well tolerated.

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.

To analyze the long-term survival factors associated with HIV infection, a prospective follow-up study of 165 HIV-infected patients was performed after a clinical, nutritional, and biological evaluation. Survival rate could be determined in 129 patients after a follow-up of 42 mo before the use of protease inhibitors. After univariate analysis, multivariate analysis was performed with the Cox regression proportional-hazard model. Survival curves were calculated and compared with the Kaplan, Meier, and log-rank tests. The study also analyzed the factors associated with impaired nutritional status at the beginning of the study and their effects on the long-term follow-up. Factors that could explain body weight loss before the study were the level of intakes, resting energy expenditure, chronic diarrhea, and the number of previous opportunistic infections. In the long-term follow-up, univariate analysis showed that nutritional status could be separated into four classes of body weight loss (BWL) by degree of loss (BWLor = 5%, 5%BWLor = 10%, 10%BWLor = 20%, BWL20%); lean body mass (adjusted to height), body cell mass, CD4 count, albumin, prealbumin, and C-reactive protein (CRP) were all significant predictors. Age, stage of disease, number of previous opportunistic infections, and antiviral therapies were not associated with a change in survival. With the multivariate model, only CD4 counts, lean body mass/height squared, and CRP remained significant independent predictors of survival after controlling for other factors.

To evaluate the efficacy of total parenteral nutrition in AIDS patients.A prospective, randomized, controlled, multicentre trial.Over a period of 2 months, 31 malnourished and severely immunodepressed AIDS patients were assigned to receive either dietary counselling (n = 15) or home total parenteral nutrition (TPN; n = 16) via a central venous access after an educational program. Results were analysed by intent-to-treat basis.Bodyweight change was +8 kg (+13 +/- 3%) in the TPN group and -3 kg (-6 +/- 2%) in the control group (P0.0006). Lean body mass increased in the TPN group (+9 +/- 3%) and decreased in the control group (-5 +/- 3%; P0.004) while body cell mass increased in the former (+15 +/- 4%) and decreased in the latter (-12 +/- 6%; P0.002). Nutritional subjective global assessment, subjective self-reported health feeling and Karnofsky index were also improved by TPN. Infection line sepsis incidence remained low (0.26 per 100 patient-days). However, no difference in survival rate was exhibited between the two groups by the log-rank test.We conclude that home TPN is an efficient treatment of malnutrition in severely immunodepressed AIDS patients.

The assessment of nutritional status of patients should rely on sensitive and specific evaluation tools. However a universally recognized criterion of severity of denutrition is still lacking. The most important clinical indicator is the weight. The speed of weight loss is an important point to consider: a loss of 2% within one week is equivalent to 5% in one month and 10% in six months. Other anthropometric indices such as the triceps skin fold and the mid arm muscle circumference have not shown, when considered alone, to increase the risk carried by denutrition. Therefore other clinical indicators have to be considered, the association of which is suggestive of malnutrition, but none when considered alone is neither specific nor pathognomonic. Food intake is quantified by questioning. Among the biological markers representative of the pool of circulating visceral proteins is albumin. Numerous studies have demonstrated a morbidity and mortality increase when the plasmatic albumin concentration is less than 30 g.L-1. Other proteins with a shorter half-life, such as transferin, prealbumin and retinal binding protein have been recommended. The determination of muscular mass is also a tool for nutritional assessment. The muscular function and immunologic tests such as the lymphocyte count and cutaneous reactivity to various antigens have been assessed as denutrition indices. The determination of body mass composition by bioelectrical impedance could become the technique of choice for nutritional assessment. However its use for peri-operative evaluation has not been validated prospectively. Because of the lack of reliability of markers when considered alone, several authors produced multivariate nutritional indices.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of malnutrition and refeeding on nutritional indices, pulmonary function, and diaphragmatic contractile properties were studied in severely malnourished patients with anorexia nervosa. Fifteen patients were evaluated upon hospital admission (Day 0) and on Days 7, 30, and 45 after starting feeding. Spirometry, lung volumes, and arterial blood gases were measured at each time interval, as were contractile properties of the diaphragm as assessed by transdiaphragmatic pressure generated during electrical phrenic nerve stimulation (Pdistim) and a maximal sniff maneuver (Pdisniff). Anthropomorphic and biochemical measurements were performed at each time interval. Patients were severely malnourished upon admission; mean body weight was 37.1 +/- 4.7 kg (63% ideal body weight). During nutritional support, body weight increased significantly to 42.9 +/- 4.6 kg on Day 45 (p0.01), as did muscle mass: 11.2 +/- 4.1 kg on Day 0, to 16.6 +/- 4.9 kg on Day 45 (p0.01). Vital capacity and FEV1 increased significantly by Day 30 (p0.05). Lung volumes were unchanged. Mean arterial blood gas values were also within the normal range at Day 0; PaO2, 92.6 +/- 2.4 mm Hg and PacO2, 41.0 +/- 1.5 mm Hg. Four patients, however, had an increased PacO2 (42 mm Hg) at Day 0, which returned to normal by Day 30. Diaphragmatic contractility was severely depressed initially; Pdistim, 15.9 +/- 1.4 cm H2O; Pdisniff, 65.4 +/- 5 cm H2O; but it significantly increased with nutritional support by Day 30 to 22.5 +/- 1.9 and 84.6 +/- 4.7 cm H2O, respectively. We conclude that diaphragmatic function is severely impaired in malnuorished patients free of other coexisting