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Diet is a major environmental source of proinflammatory AGEs (heat-generated advanced glycation end products); its impact in humans remains unclear. We explored the effects of two equivalent diets, one regular (high AGE, H-AGE) and the other with 5-fold lower AGE (L-AGE) content on inflammatory mediators of 24 diabetic subjects: 11 in a 2-week crossover and 13 in a 6-week study. After 2 weeks on H-AGE, serum AGEs increased by 64.5% ( P = 0.02) and on L-AGE decreased by 30% ( P = 0.02). The mononuclear cell tumor necrosis factor-α/β-actin mRNA ratio was 1.4 ± 0.5 on H-AGE and 0.9 ± 0.5 on L-AGE ( P = 0.05), whereas serum vascular adhesion molecule-1 was 1,108 ± 429 and 698 ± 347 ng/ml ( P = 0.01) on L- and H-AGE, respectively. After 6 weeks, peripheral blood mononuclear cell tumor necrosis factor-α rose by 86.3% ( P = 0.006) and declined by 20% ( P , not significant) on H- or L-AGE diet, respectively; C-reactive protein increased by 35% on H-AGE and decreased by 20% on L-AGE ( P = 0.014), and vascular adhesion molecule-1 declined by 20% on L-AGE ( P < 0.01) and increased by 4% on H-AGE. Serum AGEs were increased by 28.2% on H-AGE ( P = 0.06) and reduced by 40% on L-AGE ( P = 0.02), whereas AGE low density lipoprotein was increased by 32% on H-AGE and reduced by 33% on L-AGE diet ( P < 0.05). Thus in diabetes, environmental (dietary) AGEs promote inflammatory mediators, leading to tissue injury. Restriction of dietary AGEs suppresses these effects.

Although severity of illness remains an important predictor of in-ICU mortality and mortality at 6 months after release from ICU, we found that impaired nutritional status upon admission was related to 6-month mortality. These results emphasize the need for a systematic nutritional assessment in older patients admitted to the ICU and treated by mechanical ventilation.

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The aim of this practical review was to revalidate subcutaneous infusion or hypodermoclysis in the older subject and to set out its indications and limitations, its contraindications, and its techniques and methods of surveillance. Hypodermoclysis is an effective technique for the prevention or cure of moderate dehydration, although it cannot be used in place of intravenous infusion in cases of severe dehydration. Hypodermoclysis is simple and safe. It is the least aggressive of infusion techniques and thus avoids hospital, admission and reduces health costs. Infusion of a solution of amino acids can also limit the consequences of low protein intake for a short period of time, but it will not cure severe malnutrition. The many advantages and the few disadvantages of this technique should encourage its wider use in geriatrics. SUBCUTANEOUS INFUSION OR HYPODERMOCLYSIS: A PRACTICAL APPROACHSubcutaneous infusion or hypodermoclysis was first used to overcome dehydration in pediatric patients.' However, the complications, such as pain, sepsis, and shock -which were, in fact, most often linked to practical errors -meant that it was almost abandoned in the 1950s.'The risk of dehydration is a common problem in older patients, both at home and in institution^.^ Warren et a1.4 reported that 7% of all acute admissions of older patients were associated with dehydration. Moreover, 25% of febrile older patients in nursing homes suffer from dehydration, sometimes fatally, because fluid intake is lower than the amount required, and referral to an acute unit is often necessary.' Berger stated in 1984 that in nursing homes, instigating subcutaneous infusion is often preferable to calling an ambulance.6 A recent study confirmed that effective hypodermoclysis, which is achieved in 71% of patients, reduces the need for transfer, and hence costs, ~ubstantially.~ Lipschitz's study validated the subcutaneous administration of fluids by demonstrating that a saline infusion labeled with tritium and technetium was absorbed as effectively subcutaneously as by the intravenous routea8 Dardaine et aL9 reported the metabolic and hormonal effects induced by a glucose/saline solution (5% glucose solution containing 4 g NaCI) administered by intravenous and subcutaneous routes. The smaller and delayed metabolic and hormonal changes From the 'Service de GCriatrie, HBpital de Valence, 26953 Valence Cedex 9, and tI-16pital de I'Ermitage, CHU dc Tours, 37081 Tours Cedcx 2, France.