Rôle du pharmacien dans la politique nutritionnelle à l''hôpitalPlace of pharmacist in hospital nutritional policy

Hospital pharmacists have a specific role in nutritional hospital policy. Their lawfully defined missions make them essential actors for the management of nutriments and medical devices needed for artificial nutrition techniques. Their knowledge of galenic questions allow them to ensure preparation of nutrient mixtures for parenteral nutrition in optimal quality and security conditions. Pharmacist is associated with hospital nutritional policy as a member of liaison comity between alimentation and nutrition. He takes part of home artificial nutrition when they are supported by the hospital. All of those institutional roles allow him by its knowledge in nutriments, in galenic questions, and in medical devices to support nutrition team, with which a very near collaboration is essential.     

Place et impact des régimes chez les personnes très âgées

Successful ageing promotion is a major goal of care in geriatrician patients, even in old age. Cardiovascular prevention strategy, diabetes care or kidney protection involve dietary management. However, mortality and morbidity risk factors are modified in the oldest old, and on the other hand, dietary restrictions could impair health status of the older. Studies devoted to the oldest old are scarce. In most situations, exercise training promotion seems to better address the prevention goals than do diets.     

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.     

Centralisation ou déconcentration de la production des repasCentralization or decentralization of meal production

The change of the demand of the patients’ profiles and the changes in nutritional approaches, require a new orientation in hospital catering business. The study of number of themes (modes of production, the implementation of quality systems such as ISO or HACCP up to patients’ beds, the mastery of the dinner trays assembly, the order taking and the choice of the menu) would tend to direct the current massive production to central kitchens while maintaining satellite kitchens with a lower production activity.     

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.     

Outils et procédures de dépistage de la dénutrition et de son risque en milieu hospitalierTools and procedures for screening for malnutrition and its associated in risks in hospital

Malnutrition affects on average 20–50% of hospital inpatients and its negative repercussions in terms of morbi-mortality have been fully documented. Although this state of affairs is well known, there is little screening for malnutrition in hospitals. There is no single parameter indicating malnutrition, which instead has to be diagnosed based on anthropometric and biological data, and by multi-factorial indices of nutritional risk. Screening adapted to each of the four main classes of hospital care, acute medicine and surgery, intensive care, geriatrics and paediatrics needs to be systematically performed for every inpatient. To make malnutrition screening a natural part of the practice of care, we need to design training courses, which highlight the benefits in terms of length of stay, morbi-mortality and cost.     

Modèles animaux pour les études métaboliques et nutritionnelles lors de la croissance tumoraleAnimal models of tumor growth for metabolic and nutritional studies

Diverse animal models have been used to model the complex metabolic changes involved in cancer-associate malnutrition. Transplantable tumors without anti-tumor therapy are useful to reveal catabolic mechanisms, if conducted within the limits of clinically relevant tumor burden. The few studies in which a treatment (surgery, chemotherapy) has been used suggest that malnutrition is the result of tumor-associated processes (capture of substrates; secretion of catabolic factors, alteration of the hormonal environment), of the anti-neoplastic treatments, or of interactions between these. Current approaches in nutritional intervention are focussed on the complex interplay between host and tumor, by the provision of specific amino acids (i.e., arginine, glutamine), as well as polyunsaturated n-3 fatty acids. Feeding route and diet formulation are critical elements of the research approach. Further evolved animal models representing the clinical diversity of cancer and treatments, and the key nutrients, will form a basis to develop the optimal nutritional support for the cancer patient.     

Éducation des familles et de l'enfant en nutrition artificielle à domicile

The techniques of artificial nutrition came of age since the seventies (1969 for enteral nutrition and 1973 for parenteral nutrition). Artificial nutrition has considerably modified the outcome of a great number of children with severe digestive tract pathologies or many other disorders making impossible or ineffective oral food administration. There are currently two techniques of artificial nutrition: enteral nutrition (the most physiological using the digestive tract) and parenteral nutrition (by central venous line, more demanding and more complications). Home parenteral and enteral nutrition emerged with new realities: increase in the number of children needing a nutritional assistance, increase in the number of indications and a constant need to make autonomous the child and the family leading to a better quality of life. The best care for these children needs a multidisciplinary approach (physicians, nurses, dieteticians, pharmacists, speech therapist, psychologists…) and a close relation between primary care and hospital. This also requires a significant investment of parents who are sometimes assisted by private nurses. Parents are thus educated with techniques of enteral nutrition and parenteral nutrition: use of the material, training with the care, learning the action to be taken in case of problem. They have thus a role of caregiver: heavy responsibility necessary to the return at home of their child. The educational role of the hospital team thus takes a paramount importance with the aim to provide an optimal home return and the most adequate care by the family.     

Alimentation et soins nutritionnels dans les hôpitaux : une vision européenneFood and nutritional care in hospitals: an european view

Disease-related undernutrition is significant in European hospitals but is seldom treated. 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 12 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 guidelines to improve the nutritional care and support of hospitalised 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; (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 support managers.     

Évaluation des apports alimentaires des malades hospitalisésFood intakes in in-hospital patients

Studies have shown that malnutrition may affect more than 50% of hospitalized patients. They observe a further deterioration in nutritional status during hospital stay. This deterioration may be explained by imbalance between energy and protein needs and low voluntary intake by patients. Although underfeeding is often attributable to disease or treatments, authors observe that more than 50% of causes are imputable to inadequate organization. This results in high food wastage with medical and economical consequences whose rate may be greater than 40%. Improvements of dietary intakes depend on the development of a screening and assessment system. This includes to promote an educational program for doctors and nurses, to modify the hospital diet according to the patients’ preferences and needs, to help and monitor dietary intakes in patients with undernutrition at admission or at risk of malnutrition.     

Stress oxydant au cours des états inflammatoires aigus et des états d’agression : implications pour la pratique cliniqueOxidative stress during acute inflammatory and critical states: implications for clinical practice

Oxygen free radicals (OFR) production and consumption are balanced in health. In acute inflammatory disease, OFR may overwhelm host defence mechanisms, a condition known as oxidative stress. They have been implicated in the pathogenesis of a wide variety of diseases. Oxidative stress plays a pivotal role in inflammatory situations and critical illness such as Systemic Inflammatory Response Syndrome, septic shock, adult respiratory distress syndrome, burns, trauma, and renal failure. Deficiencies in anti-oxidant defences include depletion of glutathione, vitamins A, C and E and selenium. Preventing the initiation or controlling the progression of local or systemic disease processes that complicate the course of critically ill patients with anti-oxidant therapies is an actual strategy. This review will present trials with single or multiple anti-oxidant therapies in critical situations. These studies strongly suggest that patients should benefit from anti-oxidant therapy. To date, data to support routine use of anti-oxidants in critical illness are limited. The choice of anti-oxidants dosage and appropriate target populations must be better defined.     

Les espèces réactives de l’azote : bénéfiques ou délétères ?Reactive nitrogen species: deleterious or not?

NO^• exerts many effect on the organism, either beneficial or detrimental. Beneficial ones are mainly mediated by NO^• itself (through activation of guanylyl cyclase—the cGMP-dependent pathway—or through S-nitrosylation) in a specific microenvironment, generated at low concentrations by endothelial or neuronal NO-synthases in a regulated manner. By contrast, prolonged and high-ouput inducible NOS-derived NO^• may exert both oxidative and nitrosative stress, respectively through peroxynitrite-mediated oxidation, nitration and oxidative nitrosylation and through dinitrogen trioxide-mediated nitrosation. Integration of all determinants of the net effect of NO^• is complex and is the topic of intensive research for potential adapted, selective and titrated treatment.     

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.     

Nutrition au cours des radiothérapies et chimiothérapiesNutritional support during cancer chemotherapy and radiotherapy

Nutritional support for cancer patients treated with radiotherapy and chemotherapy are strongly requested with regard to the frequent malnutrition at time of diagnosis. Furthermore, the malnutrition often progresses with adverse effects of therapy and disease progression. Nutritional screening and assessment are essential. Dietetic care is mandatory for patients with malnutrition or at risk of malnutrition when they are still able to eat. But this oral nutritional support is frequently unable to maintain sufficient nutritional intakes with regard to tumour effect or treatment toxicity. Enteral or parenteral nutrition must be provided to patients unable to absorb adequate quantity of nutrients for a prolonged period. The primary goal is to avoid, especially for malnourished patients, further nutritional degradation which can lead to treatment interruptions, complications or increased risk of death. Routine administration of artificial nutrition has been tested during radiotherapy and chemotherapy but results are conflicting and data are missing for severely malnourished patients. No benefits in terms of treatment toxicity, tumour response, risk of complications and finally mortality have been demonstrated for routine use of artificial nutrition. Most decisions for indication of nutritional support, route of administration and quality of artificial nutrition in this field can't rely today on evidence-based medicine. However, artificial nutrition can provide nutrients and hydration necessary to maintain comfort and to improve survival for patients unable to eat sufficient nutrition for a prolonged period.     

Évaluation de l'état nutritionnel et des besoins de l'enfant et de l'adolescent

Ten to fifteen percent of hospitalized children suffer from malnutrition. Children suffering from chronic diseases are at particularly high risk for malnutrition. A systematic screening for malnutrition and nutritional risk can improve nutritional care in this population. Simple measures (weight and height at admission) can be used to calculate nutritional indices (weight for height ratio or body mass index). Nutritional risk depends on: 1) the severety of the principal diagnosis, 2) the ability to feed oneself, and 3) the pain intensity. The oral or enteral route is preferred when the gut is functional. In all cases nutritional status must be followed throughout hospitalisation. Furthermore, it is preferable to begin nutritional care before malnutrition sets in. Nutritional care can improve the outcome and well-being of hospitalized children.     

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.