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.     

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.     

Stratégies de prise en charge nutritionnelle spécifiques : l'enfant et l'adulte jeune atteints d'un handicap

Handicapped children are at high risk for malnutrition. In this situation nutritional assessment becomes difficult to perform due to musculo-skeletal deformities, patient's collaboration. In any case nutritional indices require simple measures: weight and height. Nutritional care must be presented early to parents in order to start as soon as possible when oral intake does not meet nutritional needs. For the handicapped child, surgery is often a major stress that requires nutritional care before, during and after. Obesity often aggravates the burden of the handicap and does not provide protection against malnutrition. Like in non-handicapped persons nutritional care can improve the outcome and well being of handicapped children.     

Stratégies de prise en charge nutritionnelle spécifiques : l'enfant en cancérologie

In children with cancer, malnutrition may antedate the diagnosis or be a result of aggressive chemotherapeutic regimens. The prevalence of malnutrition at diagnosis is related to the type of tumour and the extent of the disease, ranging from < 10% in patients with standard-risk acute lymphoblastic leukaemia to 50% in children with advanced neuroblastoma. The pathogenis of the energy imbalance that underlies the development of malnutrition is complex, including increased breakdown of fat and protein as well as energy-consumptive changes in carbohydrate metabolism (Cori cycle). Despite several confounding factors (different definitions of nutritional status and the wide variety of measures used for its assessment), studies have shown decreased tolerance of chemotherapy associated with altered metabolism of antineoplastic drugs, increased infection rates, altered quality of life and possibly poor clinical outcome in malnourished patients. In this article, we review guidelines for the nutritional management of a child with cancer and we purpose an algorithm for nutritional support.     

Citrulline et métabolisme protéique

Circulating citrulline is more than an intermediary metabolic product. This amino acid synthesized by enterocytes of intestinal mucosa is not included in proteins and is a precursor for renal production of arginine by kidney. Anabolic role of citrulline — that escape to hepatic metabolism — on nitrogen balance and muscular proteins was shown in experimental animal models. This is the basis for clinical experimentation of citrulline in malnutrition with increase of splanchnic sequestration as in elderly subjects. Moreover, citrulline is, in clinical situation, an established biomarker of enterocyte metabolic mass in children and in adult patients due to its high relation to functional small bowel remnant length. Plasma citrulline concentration less than 10–20 μmol/L can give an objective threshold for nutrition parenteral use in case of intestinal failure due to enterocyte abnormalities or lack.     

Prise en charge nutritionnelle préopératoire

Undernutrition is an independent factor of postoperative morbidity and mortality. The aim of a preoperative nutritional support is to enhance immune, muscular and cognitive functions, and to support wound healing. This nutritional support (e.g. dietary management, enteral or parenteral nutrition) should be limited to high-risk situations with a beneficial effect of nutrition for the patient: undernutrition, major surgery and elderly. Preoperative nutritional support should be scheduled for at least 7 to 10 days before the surgery. During the preoperative period, the type and route of an eventual postoperative nutritional assistance should be anticipated. In the case of emergency surgery, nutritional assessment of the patient should be done as soon as possible before surgery or in the 48-h postoperative period. Finally, in elective surgery, preoperative fasting should be limited to 2–3 hours for clear liquids and 6 hours for solids.     

Stratégie de prise en charge nutritionnelle de l'enfant et de l'adolescent (Nutrition orale, entérale, parentérale)

Children are especially threatened by malnutrition, because of the high protein-energy cost of growth. Any nutritional deficiency is the source of protein energy malnutrition, which compounds the problems of underlying disease. The protein-energy cost of catch-up growth is particularly high, and should lead to a rigorous adjustment of nutritional supply to prevent metabolic disorders associated with refeeding syndrome (directly related to the homeostatic change secondary to severe protein energy malnutrition). If the gastrointestinal tract can be used for refeeding, it should be used (oral or enteral nutrition). When the gastrointestinal tract is unable to meet the protein and energy requirements, parenteral nutrition is required. Catch-up growth may be achieved by using appropriate nutritional support.     

Place de la pharmaconutrition en périopératoire

Since 20 years, data from high quality studies have demonstrated that perioperative immunonutrition is able, even in well-nourished patients, to reduce septic complications, length of stay and costs, in elective digestive cancer surgery. Then update of recommendations for clinical practice has been proposed. As this treatment is effective, French system reimburses the cost of treatment since 2006. Educational programme is now necessary to diffuse state of art.     

Étude de la cytotoxicitéin vitro de dérivés du carbazole III. 3-Amino et 3-nitro-1,4-diméthyl-9H-carbazoles diversement substitués en position 6

La synthèse d'une série de 3-nitro et 3-amino-1,4-diméthyl-9H-carbazoles diversement substitués en positions 6 et 8 est décrite. Leur activité cytotoxique, évaluée in vitro au moyen de la culture clonogénique de la leucémie L1210, dépend fortement de la nature et de la position des substituants. Le plus cytotoxique d'entre eux, le dérivé 3-amino 6-hydroxy, présente une cytotoxicité comparable à celle de l'acétate de N2-méthyl-9-hydroxy ellipticinium (NMHE). Ces résultats et ceux présentés dans les deux publications précédentes, permettent une discussion détaillée des relations structure-activité dans la série du 9H-carbazole et du 1,4-diméthyl 9H-carbazole et suggèrent, pour les dérivés du 3-amino 1,4-diméthyl 9H-carbazole, un mécanisme d'action proche de celui des dérivés de l'ellipticine.     

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.