Hypermetabolism is a deleterious prognostic factor in patients with amyotrophic lateral sclerosis.

BACKGROUND AND PURPOSE: The aim of this study was to investigate patients with amyotrophic lateral sclerosis in order to determine their nutritional, neurological and respiratory parameters, and survival according to metabolic level. METHODS: Nutritional assessment included resting energy expenditure (REE) measured by indirect calorimetry [hypermetabolism if REE variation (ΔREE) > 10%] and fat mass (FM) using impedancemetry. Neurological assessment included the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised score. Survival analysis used the Kaplan-Meier method and multivariate Cox model. RESULTS: A total of 315 patients were analysed. Median age at diagnosis was 65.9 years and 55.2% of patients were hypermetabolic. With regard to the metabolic level (ΔREE: < 10%, 10-20% and >20%), patients with ΔREE > 20% initially had a lower FM(29.7% vs. 32.1% in those with ΔREE ≤10%; P = 0.0054). During follow-up, the median slope of Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised tended to worsen more in patients with ΔREE > 20% (-1.4 vs. -1.0 points/month in those with ΔREE ≤10%; P = 0.07). Overall median survival since diagnosis was 18.4 months. ΔREE > 20% tended to increase the risk of dying compared with ΔREE ≤10% (hazard ratio, 1.33; P = 0.055). In multivariate analysis, an increased REE:FM ratio was independently associated with death (hazard ratio, 1.005; P = 0.001). CONCLUSIONS: Hypermetabolism is present in more than half of patients with amyotrophic lateral sclerosis. It modifies the body composition at diagnosis, and patients with hypermetabolism >20% have a worse prognosis than those without hypermetabolism.

Diet, Alcohol Consumption and Cognitive Disorders in Central Africa: A Study from the EPIDEMCA Program.

Western research into dementia has focused on finding effective means of prevention, particularly through nutrition. To date, however, little is known about the relationship between diet and cognitive disorders in Africa, where the number of people with dementia is expected to increase most over the coming decades. The objective of the study was to investigate the relationship between diet and alcohol intake and cognitive disorders among elderly people in Central Africa. Between 2011 and 2012, a cross-sectional multicentre population-based study was carried out in rural and urban areas of the Central African Republic (CAR) and the Republic of Congo (ROC). Participants aged ≥65 years were interviewed using the Community Screening Interview for Dementia (CSI-D). Elderly people who performed poorly (COGSCORE≤24.5/30) were clinically assessed by neurologists and underwent further psychometric testing. DSM-IV and Petersen criteria were required for a diagnosis of dementia or mild cognitive impairment (MCI), respectively. A food frequency questionnaire assessed the intakes of dairy products, fruit, vegetables, starches, legumes, oleaginous foods, meat or fish, eggs and sweet foods over the previous three days. We also collected data on alcohol intake. Sociodemographic, vascular, and psychological factors were documented. Multivariate multinomial logistic regression models were used to estimate the associations. In fully adjusted models, a lower consumption of oleaginous foods was associated with MCI (OR=3.7 [1.4-9.9]) and dementia (OR=2.8 [1.0-7.7]) in a rural area of CAR. Alcohol consumption was associated with reduced probability of dementia in CAR (OR=0.3 [0.1-0.8]). In ROC, food groups and alcohol intake were not associated with MCI or dementia. In conclusion, our study provides new data about the association between diet and cognitive disorders in Africa. Further studies should investigate the relationship between diet and cognitive disorders at the level of specific foods rather than food groups.

The nutritional status of older people with and without dementia living in an urban setting in Central Africa: the EDAC study.

OBJECTIVES: To determine the nutritional status of elderly African people and to investigate the association between undernutrition and dementia. DESIGN: Door-to-door cross-sectional surveys in the general population. SETTING: Representative districts of Bangui (Central African Republic) and Brazzaville (Republic of Congo). PARTICIPANTS: Population aged over 65 years. MEASUREMENT: Undernutrition was defined as a body mass index <18.5. Anthropometric parameters (arm circumference, waist circumference and triceps skinfold thickness) were measured, and information was gathered on nutritional habits. PARTICIPANTS underwent cognitive screening using the Community Screening Interview for Dementia (CSI-D) and the Five-Word Test. After further neuropsychological testing and neurological examination, the diagnosis of dementia was confirmed according to DSM-IV criteria. Multivariate logistic regression models were applied in order to identify factors associated with undernutrition in populations with or without dementia. RESULTS: 1016 people were included. In the general population, the prevalence of undernutrition was 19.2%. Dementia was found in 7.4% of elderly people. Compared with healthy people, patients with dementia had an increased prevalence of undernutrition (32.0% vs. 17.7%; p = 0.002), lower weight (49.3 ± 10.5 kg vs. 58.4 ± 13.5 kg ; p < 0.001), and lower BMI (20.8 ± 4.1 vs. 22.9 ± 4.8 ; p < 0.001); they were less likely to eat their fill (38.9% vs. 45.9% ; p = 0.001), had more dietary restrictions (36.1% vs. 24.3% ; p = 0.03) and ate less often with their family (66.7% vs. 90.6% ; p < 0.0001). Eating only one meal per day was the sole factor associated with undernutrition in dementia (OR: 7.23 [CI: 1.65-31.7]; p = 0.03). CONCLUSION: The prevalence of undernutrition is high in the older population. The nutritional status of patients with dementia is more impaired than that of healthy patients. However, they are less often malnourished than in French home care settings. This study is the first to look at the nutritional status of at-home patients with dementia in Africa. These comparative data will eventually be used in the development of new nutritional intervention strategies.

Nutritional assessment and follow-up of residents with and without dementia in nursing homes in the Limousin region of France: a health network initiative.

INTRODUCTION: Limousin in France has the second oldest regional population in Europe, with people over 65-years-old who have Alzheimer's disease accounting for more than 9%. In France as a whole, a large number of residents in nursing homes (NH) have dementia, leading to many nutritional problems. LINUT is a health network that assesses the nutritional status of elderly NH residents and provides support where necessary. Aims of the present study were to use this network to evaluate the nutritional status of NH residents with and without dementia and to review changes after 4 months of intervention. METHODS: A cross-sectional survey was conducted by a doctor and a dietician at baseline (T0) and 4 months (T4) among residents at the 26 NH in Limousin that agreed to take part. The evaluation criteria included presence of dementia, depression and autonomy, weight, height, body mass index, Mini Nutritional Assessement (MNA™), and a 3-day survey of food intake. RESULTS: The 346 residents assessed at T0 were aged 87.9±6.9 years, 83.4% were women, 66.8% had dementia, 53.3% were malnourished and 27.4% obese. Autonomy was not affected by obesity. Residents with dementia had a lower Activities of Daily Living score and a lower weight than non-demented individuals (2.2±1.2 vs. 2.7±1.7 p=0.03 and 60.1±16.3 vs. 64.7±20.0 kg p=0.03, respectively), were more often malnourished (56.1% vs. 46.4% p=0.004) and less often obese (22.0% vs. 39.1% p=0.004) but consumed more protein (62.6±17.8 vs. 58.2±16.9 g/d p=0.04, 1.1±0.4 vs. 1.0±0.4 g/kg/d p=0.005). Energy intake was at the lower limit of French recommendations (26.4±8.8 vs. >25.0 kcal/kg/d). Assessment of all residents at T4 showed improved MNA™ (+0.4 points/month p=0.02), protein intake (+3.3 g/d p=0.0007), and energy intake (+41.4 kcal/d p=0.01 and 0.1 kcal/kg/d p=0.03). Variations in prevalences of malnutrition and obesity were not statistically significant. MNA™ increased in the dementia group (+0.29±0.8 points/month p=0.003). All other changes were comparable, and nutritional status did not differ more between the two groups at T4 than at T0. CONCLUSION: The prevalence of dementia was high in the population studied. Malnutrition was the main problem, particularly if residents had dementia. Protein intake was satisfactory, but energy intake often insufficient. The nutritional status of dementia patients improved after 4 months of follow-up, suggesting that effective action to support such services would be worthwhile.

Analysis of the food consumption of 87 elderly nursing home residents, depending on food texture.

OBJECTIVES: Texture-modified food (chopped, mashed, or mixed) is often used for patients, and particularly for dependent elderly people facing swallowing disorders or dental problems. Food must be energy and protein enriched, because dilution is needed for preparation, and several meals like bread can be removed. The aim of the study was to assess the food consumption of residents in four French nursing homes depending on diet texture. DESIGN/PARTICIPANTS/MEASUREMENTS: The food consumption of 87 elderly people followed by a nutrition network, randomly taken and living in nursing homes in which texture-modified food enrichment was practiced was evaluated according to the type of texture used. RESULTS: 13.8% of residents had chopped texture and 29.9% mixed texture. There was no relationship between used food textures and nutritional status residents. Calorie consumption was below the recommended intakes for elderly nursing home residents in France, whatever the type of texture. The mixed texture had more protein than the normal one and was better balanced regarding fat intake. Protein consumption was at the lower limit of the recommended intakes. Residents in overweight were those whose food consumption relative to their weight was the lowest. CONCLUSION: It seems important to check the mode of preparation of texture-modified food in nursing homes and to assess the real energy and protein consumptions of residents receiving this food.

Alteration of nutritional status at diagnosis is a prognostic factor for survival of amyotrophic lateral sclerosis patients.

OBJECTIVES: The aims were to analyse changes in nutritional parameters from diagnosis of amyotrophic lateral sclerosis (ALS) to death and to assess their relationships with survival at the time of diagnosis and during follow-up. METHODS: 92 ALS patients were included and clinically assessed every 3 months (ALS functional rating scale, manual muscular testing, forced vital capacity, weight, BMI, percentage weight loss). Bioimpedance was performed to evaluate body composition (fat-free mass, fat mass and hydration status) and phase angle. Survival analyses were performed from diagnosis to death or censoring date using a Cox model. RESULTS: The evolution of nutritional parameters in ALS patients was marked by significant decreases in weight, BMI, fat-free mass and phase angle, and increased fat mass. The authors identified an adjusted 30% increased risk of death for a 5% decrease from usual weight at time of diagnosis (RR 1.30; 95% CI 1.08 to 1.56). During follow-up, the authors identified adjusted 34% (95% CI 18% to 51%) and 24% (95% CI 13% to 36%) increased risks of death associated with each 5% decrease in usual weight and each unit decrease in usual BMI, respectively (p<0.0001). Malnutrition during the course was related to a shorter survival (p=0.01), and fat mass level was associated with a better outcome (RR 0.90 for each 2.5 kg fat mass increment). CONCLUSIONS: Nutritional parameters of ALS patients worsened during evolution of the disease, and worse nutritional status (at time of diagnosis or during the course) was associated with a higher mortality. This study offers some justification for studying the use of therapeutic nutritional intervention to modify the survival of ALS patients.

Hypermetabolism in ALS patients: an early and persistent phenomenon.

The malnutrition common among patients with ALS can be attributed in some cases to increased resting energy expenditure (REE). However, the origins and evolution of this hypermetabolism have yet to be fully elucidated. The aim of the present study was to monitor REE over time in patients with ALS and to identify factors that may explain any variation observed. ALS patients underwent nutritional, neurological and respiratory assessment every 6 months for 2 years (or until they died or became physically incapable of being examined). Sixty-one patients were studied. At inclusion, 47.5% exhibited hypermetabolism, with a mean measured REE (mREE) 19.7 +/- 6.4% higher than the mean calculated REE (cREE) (P < 0.0001). The hypermetabolism persisted when mREE was normalized for fat free mass (FFM): 35.1 +/- 4.2 versus 32.3 +/- 4.7 kcal/kg day(-1) (P = 0.02) in hypermetabolic and normometabolic patients, respectively. In univariate analysis, mREE was negatively correlated with age and positively correlated with BMI, FFM, energy and protein intakes, and albumin level. No correlation was found with neurological scores, disease characteristics, respiratory function and survival. Multivariate analysis revealed no significant factors. Only 10 of 45 patients in whom REE was measured at least twice changed their metabolic status. Neither mREE nor mREE/cREE varied significantly over time, despite deteriorating neurological, nutritional and respiratory parameters (P < 0.0001), and an increase in mREE/FFM (P = 0.01). This study confirms that about 50% of ALS patients are hypermetabolic, and 80% show no change in metabolic status over time. Thus, metabolic status (a clinically useful indicator of the need for nutritional support) can be determined early in the evolution of the disease. The origin of hypermetabolism in this context remains unknown, but growing evidence points to mitochondria as having an important role.

[Announcement of amyotrophic lateral sclerosis diagnosis]. / Modalités et contenu de l'annonce du diagnostic de sclérose latérale amyotrophique sporadique.

Breaking the news of amyotrophic lateral sclerosis (ALS) is considered as a daunting task in most cases and is not a standardizable procedure. However, proven techniques exist to reduce the trauma to the patient. Announcing ALS falls upen the neurologist who must respect the ethical principle of the patient's independence. After the diagnosis is firmly established, the patient should be informed that he or she has a progressive disease of the motor nerves, for which no curative therapy is available. The name of the disease must be stated and explained. If the family history is negative, it is reassuring for the patient and family to know that their children are unlikely to be at risk. Positive aspects (no pain, no disturbances in sensation, cognition, memory and continence) should be stressed as well as the availability of efficient palliative measures for practically all symptoms. Current research efforts, and when available, the possibility of taking part in clinical studies of new drugs should be pointed out as a means of hope. The answer to the question of prognosis should include the information that there are no sudden worsenings to be expected, that the course of ALS may vary between months and decades, that making a firm statement on prognosis all but impossible for any single patient and that respiratory function may worsen during the disease course. It is therefore mandatory to inform patients and families about the existence of ALS patients'associations. The way the patient is told the diagnosis is of great importance and is considered as a multiple-step procedure. Discussion should take place in a private and quiet room and respect some fundamental objectives such as finding out what the patient already knows or suspects and how much more the patient wants to know, observing and responding to the patient's reactions, reinforcing the information and planning the future. It is proven that communicating the diagnosis of ALS in an empathetic fashion is an important and sensitive step to disease management.

[Nutritional assessment in amyotrophic lateral sclerosis patients]. / Evaluation de l'état nutritionnel lors de la sclérose latérale amyotrophique.

During ALS, malnutrition may occur. The causes are multiple. A reduction in caloric and protein intakes, due to swallowing disorders, play a major role. Moreover, (2/3) of patients develop an hypermetabolism of unknown cause, leading to an increase in resting energy expenditure. Malnutrition, whose prevalence is 10-55 percent, is an independant significant prognostic factor for survival. Nutritional assessment is recommanded every 3-6 months at least, and more often if needed. After a simple clinical examination, nutritional assessment includes the measurement of weight (W) and height (H), in order to calculate the Body Mass Index (BMI=W/H(2)). BMI<18.5 (age: 18-65ys) or<20kg/m2 (age>65ys) indicates malnutrition. A weight loss more than 5 to 10 percent of usual weight in the last six months is another malnutrition criterion. The measurement of skinfolds and the calculation of mid arm muscle circumference give informations on respectively fat mass and fat-free mass, but their interest is mainly during the follow-up, or for triceps skinfold when included in a validated bioimpedance formula. Bioimpedance analysis (BIA) is a simple bedside technique, recently validated for measurement of fat-free mass in ALS patients. The BIA phase angle could be an easy obtained parameter of severity. Dietary interview is important when patients still use oral route, but is difficult if they have elocution or writing problems. Indirect calorimetry and dual X-ray absorptiometry give reliable informations on respectively energy expenditure and body compartments, but remain scarcely used. Additional methods, like swallowing tests, psychological, digestive or respiratory assessments are often useful for optimal nutritional prescriptions. We recommand as minimal nutritional assessment a systematic clinical examination, anthropometric measurements and bioimpedance evaluation.

Evaluation of the microbial safety of a new 1.5 l enteral feeding diet reservoir system.

BACKGROUND & AIMS: Microbial safety is essential during enteral nutrition (EN) as it can be the origin of gastrointestinal symptoms, but can also lead to systemic infections. The use of large-volume diet reservoirs could limit the risk of contamination and reduce nursing time, due to fewer repeated manipulations. The aim of the study was to evaluate in vivo the microbial safety of a new 1.5l enteral feeding diet reservoir system. METHODS: After validation of the study settings under standard laboratory conditions, 86 EN lines with sealed fittings were connected to 1.5l diet reservoirs under hospital/patient conditions. Microbial identification and quantification at different sampling times and points were performed. RESULTS AND CONCLUSIONS: No microbial contamination was observed in the diet reservoirs and in the nutrition lines above the drip chamber, demonstrating the microbial safety of this system. Retrograde contamination of the distal nutrition line end at completion of EN was observed and may be affected by the cumulative time of use of the tube. The contaminating microbial species were essentially bacteria of normal oral and digestive flora.

[Review of nutritional and respiratory support in ALS]. / Prise en charge nutritionnelle et respiratoire des patients atteints de Sclérose Latérale Amyotrophique (SLA).

During the evolution of amyotrophic lateral sclerosis (ALS), quality of life and survival of patients are related to respiratory and nutritional status. After diagnosis, a multidisciplinary care has to be promptly organized and coordinated by the referring neurologist. The nutritional and respiratory support imply that neurologists know their specific means of evaluation with their sensitivity and sensibility and be able to recognize clinical risk situations. The informations of patients on assisted-ventilation and nutritional support by using gastrostomy may be done early, precisely and trustfully. Well informed patient's choices must be respected. Nutritional and respiratory supports may be based on recommendations established by the American Academy of Neurology. This review will present and discuss their main aspects in patients with ALS.

[Standards, options and recommendations: nutritional support in palliative or terminal care of adult patients with progressive cancer]. / Standards, options et recommandations: nutrition en situation palliative ou terminale de l'adulte porteur de cancer évolutif.

CONTEXT: The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the National Federation of Comprehensive Cancer Centres (FNCLCC), the 20 French Cancer Centers 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. OBJECTIVES: To develop clinical practice guidelines according to the definitions of the Standards, Options and Recommendations project for nutritional support in adult patients with advanced or terminal cancer. METHODS: Data were identified by searching Medline, 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 95 independent reviewers. RESULTS: The main recommendations for nutritional support in adult patients with advanced or terminal cancer are: 1) Palliative care has been defined in a consensual way and is governed by the law (standard). Nutritional support is a palliative care which aim is to maintain and restore the "well-being" of the patient (standard). 2) Digestive symptoms and nutritional troubles are frequently noted in patients with advanced or terminal cancer (standard, level of evidence B2). Karnofsky index (KPS) and performance status (PS) are functional scores with a prognostic value and have to be used (standard, level of evidence B2). 3) Anorexia has a bad predictive value in patients with advanced or terminal cancer (standard, level of evidence B2). 4) In France, patients with advanced or terminal cancer are referred to medical institutions, palliative care units or remained at home (standard). Patients need a multidisciplinary follow-up (standard). An active participation of patients and/or their family circle is very important and physicians have to pay attention for their opinions (standard). 5) Dietetic counseling can help patients to improve their alimentation and its drawbacks (standard). 6) Palliative nutritional care often includes medicinal treatments (standard). 7) Artificial nutrition can slow down nutritional degradation, avoid dehydration and improve quality of life in patients with advanced stage cancer (especially head and neck cancer for enteral nutrition and digestive occlusions for parenteral nutrition) and unable to eat adapted meals (standard, level of evidence C). 8) When life expectancy is below 3 months with a KPS 3/4 50% (or PS > 2), artificial nutrition is not recommended (recommendation, expert agreement). 9) The assessment of nutritional care in patients with advanced or terminal cancer has to include functional scores measurement, quality of life and satisfaction degree of the patient and/or their family (standard, expert agreement).

Value of magnetic resonance cholangiography in the preoperative diagnosis of common bile duct stones.

OBJECTIVE: The aim of this study was to assess the performance of magnetic resonance cholangiography (MRC) in the preoperative diagnosis of choledocholithiasis. METHODS: A total of 147 consecutive patients underwent MRC for clinical and biological signs of common bile duct stones. ERCP was then carried out in 101 patients in whom there was a past history of cholecystectomy. The remaining 46 patients without a past history of biliary surgery underwent cholecystectomy and intraoperative cholangiography (IOC). The diagnosis obtained by MRC was compared with the final diagnosis established after endoscopic or surgical removal of calculi. RESULTS: A total of 113 patients had choledocholithiasis (single or multiple, including 15 cases of microlithiasis). There were no false-positive results with MRC. The false-negative results were caused mainly by small stones <3 mm in diameter, and to a lesser extent, cholangitis. Overall, the sensitivity was 93% and the specificity 100% for MRC in detecting common bile duct stones. The sensitivity and specificity of ERCP were respectively 94% and 100%, versus 93.5% and 93.3% for IOC. There was no statistically significant difference, however, between MRC and the other techniques. CONCLUSION: MRC is a key technique in the preoperative diagnosis of choledocholithiasis. Its diagnostic value is comparable to ERCP, but it appears to be more specific than IOC. Nevertheless, its diagnostic capability remains limited in cases of microlithiasis and cholangitis.

Factors correlated with hypermetabolism in patients with amyotrophic lateral sclerosis.

BACKGROUND: Amyotrophic lateral sclerosis (ALS) is a severe disease characterized by neurogenic amyotrophy and degeneration of upper and lower motor neurons. Although ALS patients usually experience reductions in fat-free mass (FFM), hypermetabolism via an undetermined source has also been reported. OBJECTIVE: The objective was to clarify the metabolic level of ALS patients. DESIGN: We measured the resting energy expenditure (REE) of 62 patients (32 men and 30 women) with ALS and investigated the factors correlated with metabolic level. Nutritional evaluation included bioelectrical impedance analysis, indirect calorimetry, and calculation of the body mass index. Neurologic assessment included an evaluation of peripheral and central neurologic deficit. Forced vital capacity was measured and smoking status was noted. A complete blood cell count was made and thyroid hormone and C-reactive protein concentrations were measured. RESULTS: Patients were hypermetabolic, by an average of approximately 10% more than in a reference healthy population. FFM, age, and the neutrophil count were significantly associated with REE. The only variable that contributed to the prediction of REE, REE/Z100 kHz (bioimpedance at 100 kHz), REE adjusted for FFM, or the ratio of measured REE to calculated REE was the neutrophil count, which explained only a small percentage of variance in the multiple regression analysis. Hypermetabolism was not associated with a reduction in respiratory function, tobacco use, hyperthyroidism, spasticity and fasciculation intensities, or infection. CONCLUSIONS: Our study corroborates the surprising finding that ALS patients are hypermetabolic. FFM, age, sex, manual muscular testing, the modified Norris limb score, weight, and an increase in circulating neutrophil counts correlated with the hypermetabolic state. Other factors may play a role in pathophysiologic processes that involve mitochondrial energy production or even sympathoadrenergic activation.

[Standards, Options and Recommendations for home parenteral or enteral nutrition in adult cancer patients]. / Standards, Options et Recommandations: Nutrition artificielle à domicile du malade cancéreux adulte.

CONTEXT: 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. OBJECTIVES: 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. METHODS: 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. RESULTS: 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).