Oxygène, stress oxydant et supplémentations antioxydantes ou un aspect différent de la nutrition dans les maladies respiratoires

Dioxygen is an element essential to our survival, our life, our development, our capacity of adaptation. Nevertheless, dioxygen is also at the origin of toxicity, acidity, deterioration, degeneration. Indeed, when the metabolism of dioxygen is altered, as in the respiratory diseases, an “oxidative stress” can appeared and induced metabolic anomalies associated with important consequences. Oxidative stress is defined as an imbalance between pro-oxidant (reactive oxygen species) and antioxidant factors, in favour of the former. The genomic, metabolic and functional modifications induced by oxidative stress were implied in the development of various degenerative diseases. Antioxidant treatments, in a nutritional or pharmacological way, appeared consequently as new potent therapies. In this review, the role of dioxygen in the cellular metabolism, and in the production of the reactive oxygen species is discussed. The negative effects of the oxidative stress on the organism are reported. Finally, the results of the studies on the nutritional antioxidant treatment firstly in the degenerative diseases, secondly in a chronic respiratory disease, the chronic obstructive pulmonary disease, are discussed in a last part.     

Réhabilitation respiratoire et prise en charge nutritionnelle dans la bronchopneumopathie chronique obstructive

Pulmonary rehabilitation is an effective therapeutic approach in chronic obstructive pulmonary disease (COPD) in term of improvement of the quality of life, dyspnea and exercice performance. It also has economical implications by reducing exacerbations, the number and the duration of the hospitalizations. Pulmonary rehabilitation is currently recommended among COPD patients presenting dyspnea, an impaired exercice performance or a reduction in their daily activity in connection with their disease inspite of an optimal treatment based on nicotinic weaning, bronchodilatators, and prevention of the infections. Pulmonary rehabilitation program may include cycle ergometry and inspiratory muscle training associated with an educational program concerning the disease and the nutritional aspects. It is recommended to carry out a precise nutritional evaluation comprising in addition to the recent weight history, a body mass index measurement (BMI) and a fat-free mass determination by impedancemetry if the BMI is between 21 and 26 kg/m². Smoking cessation, treatment of the bronchial infection and fractionned hypercaloric dietary intake are recommanded during the rehabilitation program. An oral supplementation near to 500 kcal/j, privileging the carbohydrates, is proposed in COPD patients during the rehabilitation program in case of BMI < 21 kg/m². In the litterature, this oral supplementation associated with the rehabilitation is likely to improve the outcome of training and the pronostic of the disease. In combinaison with the exercice training, anabolic steroids may have positive effects on body weight and fat-free mass by improvements in inspiratory muscle strength or exercice capacity. Nevertheless, further research is needed to confirm the effects of this anabolic intervention in term of efficacity and safety.     

Nutrition parentérale à domicile : prise en charge et suivi des incidents ; mise en œuvre des vigilances. Enquête sur la France métropolitaine

For Home Parenteral Nutrition (HPN), pharmacy had to deliver some medical devices and drugs. It comes up the following and taking care of incidents that's occurring at home with those products. The aim of the survey was making and inventory on vigilance's organization, incident's management and assessment, about HPN in France. A questionnaire was send to the main characters of HPN (by law authorized centres, services providers, custom-made makers, laboratories.) They were asked to describe their organization and to grade incidents according to their frequency. Organizations are varied and specific to each centre. The data process shows that the most registered incidents are: blended tubing of infusion sets, problems linked to industrial sets, occlusion or air bubble alarms with pumps. There are very few internal medical devices vigilance reports. An improved management would be done with generalization of a patient declaration form, a patient's practice assessment and a permanent quality improvement.     

Comparaison du mode entéral et parentéral de nutrition artificielle en pneumologie

Malnutrition is a common complication of chronic or acute respiratory insufficiencies. It can justify resorting to nutritional support. Very few studies have compared enteral and parenteral modes of artificial nutrition in respiratory diseases. However several theoretical arguments plead on behalf of the preferential use of enteral nutrition, most particularly in patients with chronic pulmonary disease in stable condition or in acute exacerbation, in adult respiratory distress syndrome and in cystic fibrosis patients.     

Mécanismes de la dénutrition chez l'enfant et l'adolescent

Malnutrition in child and adolescent is observed in various situations where there is an imbalance between the food intakes and caloric and proteic needs. Child is particularly vulnerable because its reserves are weak and its high caloric and proteic needs because of its growth. Various mechanisms leading to malnutrition were brought back and correspond to distinct clinical entities. The situations of malnutrition by exclusive mechanism of intake deficiency meet primarily in third world where they can take the form of starvation, extreme adaptive situation with prolonged fast. During situations known as of aggression like severe sepsis, polytraumatism, extended burn, surgery, malnutrition can settle quickly. Mechanism brought back in situation of acute aggression is defined classically like related to hypermetabolism with hypercatabolism. Kwashiorkor, another type of caloric and proteic malnutrition concerning child in third world, cannot be regarded as a simple caloric and proteic deficiency. It currently seems that a deficiency at the same time in macronutriments and micronutriments plays a part in genesis of this pathology. The glutathion seems in particular, to play a fundamental part in the kwashiorkor's pathophysiology. The most documented hypothesis relates imbalance between production of free radicals and mechanisms of defence. Mechanisms of repair would be insufficient, and persistence of membrane deteriorations would cause anomalies observed in kwashiorkor like oedema, hepatic overload, neurological disorders and diarrhoea.     

Définition et évolution du statut nutritionnel au cours d'une greffe osseuse allogénique (15 malades): Rôle de la nutrition parentérale et de l'apport azoté

Our work concerned 15 patients (9 males, 6 females) with a mean age of 29.5 years, having a hematologic malignant disease and undergoing allogenic bone marrow transplantation.We studied :

1. The metabolic disorders induced by the conditioning regimen (chemotherapy and total body irradiation) pregraft accompanying cytolysis (day −7, −5, −2).

2. The corrective effect of a total parenteral nutrition introduced 2 days before the transplantation and pursued during 30 days post-graft (day −2 to day 30).

3. The interest of a high calorie intake (BEE × 2) and, after randomisation, of a variable nitrogen intake (24% of the total calorie intake for group A [8 patients] and 14% for group B [7 patients]). The patient characteristics of these two groups were closely comparable. Urinary parameters were studied daily (3-methylhistidine, cratinine, nitrogen) and blood parameters weekly (transferrin, pre-albumin, albumin, retinol binding protein).

We observed globally :

-- An excellent result of the nutritional support without significant weight loss;

-- protein catabolism stopped with a recovery of synthesis of RBP after day 7 and pre-albumin from day 7;

-- a decrease in muscle catabolism.

The randomized study showed :

-- a significant difference in nitrogen excretion between group A and group B;

-- earlier and better protein synthesis recovery in group A, particularly with regard to RBP and pre-albumin.

In conclusion, we recommend for the patients undergoing bone marrow transplantation :

-- nutritional support should be introduced before the conditioning regimen;

-- a high calorie intake (BEE × 2) with a nitrogen intake between 14% and 24% of the total calorie intake;

-- cyclic parenteral nutrition should be pursued during the second and third month post-graft.

A day in the life of a Ménière's patient: understanding the lived experiences and mental health impacts of Ménière's disease

Concepts of social practice are increasingly being used to understand experiences of everyday life, particularly in relation to consumption and healthy lifestyles. This article builds on this in the context of lives disrupted and reshaped by chronic illness. It uses social practice theory to examine the lived experiences of individuals with Ménière's disease; a long‐term progressive vestibular disorder, defined by episodes of severe and debilitating vertigo, aural fullness, tinnitus and sensorineural hearing loss. Drawing on the findings of 20 in‐depth narrative interviews with Ménière's patients, and eight spousal/partner interviews, we explore the impacts of the condition on sensory, temporal, spatial and social dimensions of the body. In doing so, we highlight the intensely embodied sensory and emotional work required to maintain connections between the ‘competences’, ‘materials’ and ‘meanings’ that constitute and sustain the performance of both mundane and meaningful social practices over time. As connections between these elements of social practice are disrupted during more active phases of the condition, affected individuals may be defected from old practices and recruited to new ones, often requiring both time and social support to find meaning or pleasure in these alternative ways of being in the world.     

Place de l'impédancemétrie dans le dépistage de la dénutrition à l'hôpitalBio-impedance analysis: Screening of denutrition in hospitalized patients

The prevalence of malnutrition is high in patients and tends to worsen during the hospital stay. In the absence of one reliable method to evaluate patients, the assessment of nutritional status is based on a global approach. Body composition measurement by bio-impedance analysis (BIA) is one of these approaches. Body composition measurements can detect malnutrition or abnormal hydration. Fat free mass, fat mass, and total body water are the main body compartments that are evaluated. Determination of abnormal body composition can then guide nutritional support. The reliability of BIA depends on the equation used to predict body composition and the parameters included in the formula (weight, height, sex, age, race, etc.). These parameters allow to minimize measurement errors. Thus, formula developed for specific populations allow to evaluate the nutritional status with reasonable error rates. BIA has been found to be inaccurate with abnormal distribution of body compartments (ascites, dialysis, lypodystrophy, etc.) or extreme weights (cachexia, obesity). Multi-frequency or segmental BIA was developed to overcome hydration abnormalities and variations in body geometry. However, these techniques require further validation. The BIA seems to have some limitations. This review aims to assess the reliability of BIA to detect protein-calorie malnutrition at hospital admission or during nutritional follow-up of patients.     

Dénutrition périnatale : prise en charge nutritionnelle spécifique du nouveau-né

Malnutrition is quite rare in neonates. However perinatal malnutrition occurs in two situations. Fetal malnutrition leading to intra-uterine growth retardation with a birth weight below the lower limit for gestational age. On the other hand a postnatal relative malnutrition ("extra-uterine" growth retardation) which occurs mainly in preterm neonates. Both these situations need specific nutritional care after birth but also during the first years of life as there is probably a relationship between post-natal nutrition and health in adults (Barker hypothesis).     

Le cirrhotique face à la chirurgie : rôle de la dénutrition dans les complications infectieuses

Postoperative complications, particularly infectious complications, are more frequent in cirrhotic than in non-cirrhotic patients after abdominal surgery. This is probably the result of a decrease in antiinfectious mechanisms in cirrhotic patients, including humoral and cellular immunodeficiency and an increase in bacterial translocation. The immunodeficient status of cirrhotic patients is partly related to malnutrition. Several clinical studies have recently suggested that enteral and parenteral nutrition improve nitrogen balance and nutritional parameters in patients with chronic liver disease. Chronic or acute encephalopathy has also been improved as well as survival. However the beneficial effect of artificial nutrition on postoperative septic complications in cirrhotic patients has so far never been confirmed in a well conducted randomized study. Giving protein and energy support to patients with cirrhosis undergoing abdominal surgery, together with specific measures such as prevention of intraoperative bleeding, treatment of sodium and water retention, and antibiotic prophylaxis against intestinal gram-negative bacteria needs to be further investigated.     

Prise en charge nutritionnelle à domicile des malades cancéreuxHome artificial nutrition in cancer patients

Cancer is the first indication for home artificial nutrition in France, with rising figures. Survival of cancer patients on home parenteral nutrition is lower than that of other patients on home parenteral nutrition, due to the evolution of the underlying disease, and cancer is also associated with lower survival figures in home enteral nutrition patients. More than half of cancer patients die within the first year of home artificial nutrition. Home artificial nutrition seems to improve health-related quality of life, and may improve life expectancy in some patients. It is prescribed in patients during treatment (supportive care) or with therapeutic sequels, the indications being comparable to those in the hospital setting. Home artificial nutrition as a palliative care is much more debated, as it has not proved to increase quality of life or survival. It should be banned for patients with a life expectancy lower than three months and a Karnofsky index lower than 50. There is no specific nutrition technique for cancer patients.     

Pour l’implantation des équipes transversales de nutrition clinique à l’hôpital : le plaidoyer du pédiatreNutrition support teams in the hospitals: why and how?

Despite major advances in the quality of care in many other areas, the prevalence of malnutrition in hospitals is high and has not decreased over the last 20 years. Young children are especially threatened. Malnutrition is associated with an increase in morbidity and mortality in hospitalized patients, induces an increase in length of stay and thus, in hospital costs. The nutritional risk in hospitalized patients is related to the underlying disease and to the organization of feeding and nutrition in the hospitals. Moreover, most of the physicians and other professionals do not have enough knowledge in the area of nutrition. Therefore, the intervention of professionals specialized in nutrition is needed. These professionals must be well organized and coordinated. Two different kinds of nutritional support boards exist in hospitals. Nutrition advisory (steering) boards which include all categories of professionals involved in feeding and nutrition, set broad policies about patients’ meal service and nutrition, but do not envisage patients on an individual basis. By contrast, nutrition (support) teams (NT) are little clinical units (even without devoted beds), involving a small number of nutrition specialists including at least one senior physician, to which patients should be referred individually. The main objective of the NT is to set up optimum nutrition according to each individual situation, especially in case of need for artificial nutrition. The impact of NT intervention, in terms of patients’ outcome as well as financial benefits, has been shown for long.     

Mort criminelle par arme blanche dans la région de Kairouan,Tunisie : Etude rétrospective 2008-2018

Introduction: Homicides by stabbing are the most common forensic form of criminal death in Tunisia. These homicides represent a type of violent death that requires investigation in a forensic setting. Aim: To describe the epidemiological and forensic profile of stab wounds in the region of Kairouan, Tunisia Methods: We conducted a retrospective study of stab-wounds autopsy cases collected at the Forensic Department at the Ibn El Jazzar University Hospital in Kairouan over eleven years (01/01/2008 to 31/12/2018). Results: Forty-seven cases of homicide were retained. A male predominance was observed with a sex ratio of 22 (45H/2F, 96%). The mean age of the victims was 33.3±10.84 with ages ranging from 12 to 63 years. Most victims (79%) were of rural origin, singles (62%), and daily-laborers (89%). The months that recorded the highest numbers of homicides were November and August. The most common reason for the assault was a settling-score on the street. The perpetrator was known by the victim in 90% of cases, having used a knife as a weapon in 90% of cases. The thorax was the most frequently affected area, resulting in fatal heart wounds in 28 cases. Conclusion: Autopsy remains an essential tool for drawing up a detailed injury assessment in homicides by stabbing and determining the injury mechanism of the wounds. The comparison of the autopsy findings with the data of the judicial investigation is of great help in the legal qualification of the facts and the determination of the responsibility of the aggressors.