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Islam MR, Fahim SM, Rasul MG, Raihan MJ, Ali NM, Bulbul MMI, Ahmed T. Health Care Providers' Knowledge, Attitude, and Practice Regarding Facility-Based Management of Children With Severe Acute Malnutrition in Bangladesh. Food Nutr Bull 2022; 43:465-478. [PMID: 35982628 DOI: 10.1177/03795721221116710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Severe acute malnutrition (SAM) contributes to a substantial number of child deaths globally per year. The mortality rates can be lowered markedly if guideline-based management protocol is properly followed. However, case-fatality rates in resource-poor centers remain high even after introducing the guidelines. Perhaps, the lack of adequate knowledge leading to inappropriate management by the health care providers is responsible for such burden. OBJECTIVE We aimed to evaluate health care providers' knowledge, attitude, and practice regarding the facility-based management of children with SAM in Bangladesh. METHODS This was a qualitative study where data were collected cross-sectionally from 4 district and 2 tertiary care hospitals. Twenty-six semi-structured in-depth interviews were conducted among the doctors and nurses involved in inpatient care of SAM. Twenty-eight hours of observation were done in each facility to obtain information regarding the management practices. RESULTS The doctors had substantial knowledge in managing children with SAM in the facilities. However, knowledge of nurses was found suboptimal when evaluated based on the national guideline. Both doctors and nurses demonstrated favorable attitude toward management of childhood SAM. Identification of SAM at the facilities was poor due to lack of practice in relation to anthropometric measurements. In addition, improper practices related to blood glucose testing, dehydration monitoring, essential micronutrient administration, and follow-up of children with SAM were observed. CONCLUSION The study results underscore the importance of taking appropriate measures to enhance knowledge and ensure proper practice in relation to inpatient care of children with SAM according to the national guideline in Bangladesh.
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Affiliation(s)
- Md Ridwan Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shah Mohammad Fahim
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Golam Rasul
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammad Jyoti Raihan
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Nafi Mohammad Ali
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Mofijul Islam Bulbul
- National Nutrition Services, Institute of Public Health Nutrition, Ministry of Health and Family Welfare, Government of Bangladesh, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Office of the Executive Director, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Public Health Nutrition, James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
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Derakhshandeh-Rishehri PhD Student SM, Shenavar MSc R, Farmani Bs A, Hemmati PhD A, Faghih PhD S. The effects of nutritional support baskets on growth parameters of under five years old children with malnutrition and low socio-economic status. J Trop Pediatr 2021; 67:6139356. [PMID: 33594420 DOI: 10.1093/tropej/fmab007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Although malnutrition is globally widespread among children, there is no consensus on the most effective intervention for improving a child's growth. The present study is designed to investigate the effects of nutritional support basketson growth indices of malnourished children. METHODS This is a field trial conducted on 3667 malnourished children (0-60 months) for 9months, between 2017 and 2018, in Fars province of Iran. Weight-for-age, height-for-age, weight-for-height and body mass index-for age indices were assessed before and after the intervention with nutritional support baskets, which contains 600 kcal/day. RESULTS The baseline prevalence of moderate/severeunderweight, stunting and wasting were 31.5%, 33.3% and 28.9%, respectively. After the intervention, the prevalence non-significantly reduced to 25.5%, 31.7% and 20.35%, respectively (p > 0.05). The intervention is associated with a non-significant reduction in the prevalence of underweight and wasting in 0-23 months children, and a non-significant reduction in the prevalence of underweight, stunting and wasting in 24-60 months children. Furthermore, the intervention is associated with a non-significant reduction in the prevalence of underweight, stunting and wasting in girls, and a non-significant reduction in the prevalence of underweight and wasting in boys. CONCLUSIONS Nutrition support was effective in improving malnutrition indices of children; however, the results were non-significant. Further studies with longer period and control group areneeded to support the effectiveness of nutrition support in children.
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Affiliation(s)
- Seyedeh-Masomeh Derakhshandeh-Rishehri PhD Student
- Nutrition Research Center, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Community Nutrition, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Razieh Shenavar MSc
- Department of Community Nutrition, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Azam Farmani Bs
- Department of Community Nutrition, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Shiva Faghih PhD
- Nutrition Research Center, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Community Nutrition, Shiraz University of Medical Sciences, Shiraz, Iran
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Bourke CD, Jones KDJ, Prendergast AJ. Current Understanding of Innate Immune Cell Dysfunction in Childhood Undernutrition. Front Immunol 2019; 10:1728. [PMID: 31417545 PMCID: PMC6681674 DOI: 10.3389/fimmu.2019.01728] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 07/09/2019] [Indexed: 12/13/2022] Open
Abstract
Undernutrition affects millions of children in low- and middle-income countries (LMIC) and underlies almost half of all deaths among children under 5 years old. The growth deficits that characterize childhood undernutrition (stunting and wasting) result from simultaneous underlying defects in multiple physiological processes, and current treatment regimens do not completely normalize these pathways. Most deaths among undernourished children are due to infections, indicating that their anti-pathogen immune responses are impaired. Defects in the body's first-line-of-defense against pathogens, the innate immune system, is a plausible yet understudied pathway that could contribute to this increased infection risk. In this review, we discuss the evidence for innate immune cell dysfunction from cohort studies of childhood undernutrition in LMIC, highlighting knowledge gaps in almost all innate immune cell types. We supplement these gaps with insights from relevant experimental models and make recommendations for how human and animal studies could be improved. A better understanding of innate immune function could inform future tractable immune-targeted interventions for childhood undernutrition to reduce mortality and improve long-term health, growth and development.
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Affiliation(s)
- Claire D Bourke
- Centre for Genomics & Child Health, Blizard Institute, Queen Mary University of London, London, United Kingdom.,Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Kelsey D J Jones
- Kennedy Institute for Rheumatology, University of Oxford, Oxford, United Kingdom.,Department of Paediatric Gastroenterology & Nutrition, University of Oxford NHS Foundation Trust, Oxford, United Kingdom
| | - Andrew J Prendergast
- Centre for Genomics & Child Health, Blizard Institute, Queen Mary University of London, London, United Kingdom.,Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
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Wagnew F, Dejenu G, Eshetie S, Alebel A, Worku W, Abajobir AA. Treatment cure rate and its predictors among children with severe acute malnutrition in northwest Ethiopia: A retrospective record review. PLoS One 2019; 14:e0211628. [PMID: 30785917 PMCID: PMC6382114 DOI: 10.1371/journal.pone.0211628] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 01/17/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND More than 29 million that is an estimated 5%, under-five children suffer from severe acute malnutrition (SAM) globally, with a nine times higher risk of mortality than that of well-nourished children. However, little is known regarding outcomes and predictors of SAM in Ethiopia. Therefore, this study aims to determine treatment cure rate and its predictors among children aged 6-59 months with SAM admitted to a stabilization center. METHODOLOGY A retrospective record review was employed in SAM children at the University of Gondar Comprehensive Specialized Hospital (UOGCSH) from 2014 to 2016. SAM defined as weight for height below -3 z scores of the median World Health Organization (WHO) growth standards or presence of bilateral edema or mid upper arm circumference < 115mm for a child ≥6months age. All SAM patients with medical complication(s) or failure to pass appetite test are admitted to the malnutrition treatment center for inpatient follow-up. Data were extracted from a randomly selected records after getting ethical clearance. Data were cleaned, coded and entered to Epi-info version-7, and analyzed using STATA/se version-14. Descriptive statistics and analytic analyses schemes including bivariable and multivariable Cox proportional hazards model were conducted. RESULT Among a total of 416 records recruited for this study, 288 (69.2%) SAM children were cured at the end of the follow up, with a median cure time of 11 days. Kwash-dermatosis (AHR (Adjusted Hazard Ratio): 1.48(95% CI: 1.01, 2.16)), anemia (AHR: 1.36(95% CI: 1.07, 1.74)), tuberculosis (AHR: 1.6(95% CI: 1.04, 2.43)) and altered body temperature at admission (AHR: 1.58(95% CI: 1.04, 2.4) were independent predictors of time to cure. CONCLUSION The cure rate in SAM children was low relative to sphere standard guideline. Prognosis of SAM largely depends on the presence of other comorbidities at admission. Available intervention modalities need to address coexisting morbidities to achieve better outcomes in SAM children.
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Affiliation(s)
- Fasil Wagnew
- College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Getiye Dejenu
- College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Setegn Eshetie
- College of Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Animut Alebel
- College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Wubet Worku
- College of Health Sciences, University of Gondar, Gondar, Ethiopia
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Mogre V, Yakubu A, Fuseini M, Amalba A, Aguree S. Nurses' knowledge and attitudes regarding malnutrition in children and its management in Ghana. Curationis 2017; 40:e1-e8. [PMID: 29113439 PMCID: PMC6091586 DOI: 10.4102/curationis.v40i1.1618] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 11/28/2016] [Accepted: 10/20/2016] [Indexed: 11/22/2022] Open
Abstract
Background Malnutrition contributes significantly to child morbidity and mortality. Nurses require appropriate knowledge, skills and attitudes to prevent and treat malnutrition in children using appropriate guidelines or protocols. Objectives The aim of this article was to assess nurses’ knowledge, attitudes towards malnutrition and its management using the World Health Organization (WHO) or United Nations International Children’s Fund guidelines for the treatment of severely malnourished children and to evaluate factors associated with their knowledge and attitudes. Methods Participants included 104 nurses working in the outpatient and paediatric units or departments of four hospitals in Tamale metropolis. An 88-item questionnaire was used to measure nurses’ socio-demographic characteristics as well as their knowledge and attitudes towards malnutrition in children and its management using the WHO guidelines for the inpatient treatment of severely malnourished children. Results Nurses’ knowledge in malnutrition and its management was slightly above average (54.0%), but their attitudes were highly positive. Factors that were associated with nurses’ knowledge were number of nutrition courses undertaken in nursing school, number of years working as a nurse, receipt of a refresher course on nutrition after school and receipt of training on the guidelines. Nurses’ attitudes were associated with report of having awareness on the guidelines, number of years a nurse has been involved in the treatment of a severely malnourished child. Conclusion Nurses’ knowledge levels in the inpatient treatment of severely malnourished children were not desirable. However, their attitudes were generally positive. Receipt of previous training, awareness of the WHO guidelines, practice experience and number of years as a nurse significantly affected knowledge and attitude scores in the positive direction.
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Affiliation(s)
- Victor Mogre
- Department of Health Professions Education and Innovative Learning, University for Development Studies, Tamale.
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Ververs M, Narra R. Treating cholera in severely malnourished children in the Horn of Africa and Yemen. Lancet 2017; 390:1945-1946. [PMID: 28988791 PMCID: PMC6262880 DOI: 10.1016/s0140-6736(17)32601-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 10/04/2017] [Indexed: 11/22/2022]
Affiliation(s)
- Mija Ververs
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA.
| | - Rupa Narra
- Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Abstract
The main forms of childhood malnutrition occur predominantly in children <5 years of age living in low-income and middle-income countries and include stunting, wasting and kwashiorkor, of which severe wasting and kwashiorkor are commonly referred to as severe acute malnutrition. Here, we use the term 'severe malnutrition' to describe these conditions to better reflect the contributions of chronic poverty, poor living conditions with pervasive deficits in sanitation and hygiene, a high prevalence of infectious diseases and environmental insults, food insecurity, poor maternal and fetal nutritional status and suboptimal nutritional intake in infancy and early childhood. Children with severe malnutrition have an increased risk of serious illness and death, primarily from acute infectious diseases. International growth standards are used for the diagnosis of severe malnutrition and provide therapeutic end points. The early detection of severe wasting and kwashiorkor and outpatient therapy for these conditions using ready-to-use therapeutic foods form the cornerstone of modern therapy, and only a small percentage of children require inpatient care. However, the normalization of physiological and metabolic functions in children with malnutrition is challenging, and children remain at high risk of relapse and death. Further research is urgently needed to improve our understanding of the pathophysiology of severe malnutrition, especially the mechanisms causing kwashiorkor, and to develop new interventions for prevention and treatment.
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Affiliation(s)
- Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Peter Gilgan Centre for Research &Learning, 686 Bay Street, Toronto, Ontario, M5G 0A4, Canada
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - James A Berkley
- Clinical Research Department, KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- The Childhood Acute Illness &Nutrition (CHAIN) Network, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Robert H J Bandsma
- Centre for Global Child Health, Hospital for Sick Children, Peter Gilgan Centre for Research &Learning, 686 Bay Street, Toronto, Ontario, M5G 0A4, Canada
- The Childhood Acute Illness &Nutrition (CHAIN) Network, Nairobi, Kenya
- Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Marko Kerac
- Department of Population Health, London School of Hygiene &Tropical Medicine, London, UK
| | - Indi Trehan
- Lao Friends Hospital for Children, Luang Prabang, Laos
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
- Department of Paediatrics and Child Health, University of Malawi, Blantyre, Malawi
| | - André Briend
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
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Collins S, Sadler K, Dent N, Khara T, Guerrero S, Myatt M, Saboya M, Walsh A. Key Issues in the Success of Community-Based Management of Severe Malnutrition. Food Nutr Bull 2016; 27:S49-82. [PMID: 17076213 DOI: 10.1177/15648265060273s304] [Citation(s) in RCA: 140] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Acute malnutrition is an underlying factor in almost 50% of the 10 to 11 million children under 5 years of age who die each year of preventable causes. Inpatient treatment for severe acute malnutrition is associated with high opportunity and economic costs for affected families and health service providers. Community-based therapeutic care attempts to address these problems and to maximize population-level impact through improving coverage, access, and cost-effectiveness of treatment. The community-based therapeutic care model Community-based therapeutic care programs provide effective care to the majority of acutely malnourished people as outpatients, using techniques of community mobilization to engage the affected population and maximize coverage and compliance. People with severe acute malnutrition without medical complications are treated in an outpatient therapeutic program with ready-to-use therapeutic food and routine medication. Those suffering from severe acute malnutrition with medical complications are treated in an inpatient stabilization center according to standard World Health Organization protocols until they are well enough to be transferred to the outpatient therapeutic program. Impact of community-based therapeutic care programs Twenty-one (21) community-based therapeutic care programs were implemented in Malawi, Ethiopia, and North and South Sudan between 2000 and 2005. These programs, which treated 23,511 cases of severe acute malnutrition, achieved recovery rates of 79.4% and mortality rates of 4.1%. Coverage rates were approximately 73%. Of the severely malnourished children who presented, 76% were treated solely as outpatients. Initial data indicate that these programs are affordable, with the cost-effectiveness of emergency community-based therapeutic programs varying from US$12 to US$132 per year of life gained.
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Affiliation(s)
- Steve Collins
- Valid International Ltd, Unit 14, Oxford Enterprise Center, Standingford House, 26 Cave St., Oxford OX4 IBA, UK.
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Park SE, Kim S, Ouma C, Loha M, Wierzba TF, Beck NS. Community management of acute malnutrition in the developing world. Pediatr Gastroenterol Hepatol Nutr 2012; 15:210-9. [PMID: 24010090 PMCID: PMC3746053 DOI: 10.5223/pghn.2012.15.4.210] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 12/17/2012] [Accepted: 12/19/2012] [Indexed: 11/14/2022] Open
Abstract
Globally, acute malnutrition triggers more than 50% of childhood mortality in children under 5 years old, which implies that about 3.5 million children die of malnutrition each year. Prior to the advent of ready-to-use therapeutic food (RUTF), the management of acute malnutrition was limited to hospitals, resulting in low coverage rates with high mortality, as malnourished cases were indentified at later stages often plagued with complications. However, current availability of RUTF has enabled malnourished children to be treated at communities. Further, because RUTF is dehydrated and sealed, it has the added advantage of a lower risk of bacterial contamination, thereby prolonging its storage life at room temperature. Recent data indicate that Community Management of Acute Malnutrition (CMAM) is as cost effective as other high-impact public health measures such as oral rehydration therapy for acute diarrheal diseases, vitamin A supplementation, and antibiotic treatment for acute respiratory infections. Despite the high efficacy of CMAM programs, CMAM still draws insufficient attention for global implementation, suggesting that CMAM programs should be integrated into local or regional routine health systems. Knowledge gaps requiring further research include: the definition of practical screening criteria for malnourished children at communities, the need for systematic antibiotic therapy during malnutrition treatment, and the dietary management of severe malnutrition in children below 6 months of age.
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Akech SO, Karisa J, Nakamya P, Boga M, Maitland K. Phase II trial of isotonic fluid resuscitation in Kenyan children with severe malnutrition and hypovolaemia. BMC Pediatr 2010; 10:71. [PMID: 20923577 PMCID: PMC2973932 DOI: 10.1186/1471-2431-10-71] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Accepted: 10/06/2010] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Children with severe malnutrition who develop shock have a high mortality. Contrary to contemporaneous paediatric practice, current guidelines recommend use of low dose hypotonic fluid resuscitation (half-strength Darrows/5% dextrose (HSD/5D). We evaluated the safety and efficacy of this guideline compared to resuscitation with a standard isotonic solution. METHODS A Phase II randomised controlled, safety and efficacy trial in Kenyan children aged over 6 months with severe malnutrition and shock including children with severe dehydration/shock and presumptive septic shock (non-diarrhoeal shock). Eligible children were randomised to HSD/5D or Ringer's Lactate (RL). A maximum of two boluses of 15 ml/kg of HSD/5D were given over two hours (as recommended by guidelines) while those randomised to RL received 10 ml/kg aliquots half hourly (maximum 40 ml/kg). Primary endpoint was resolution of shock at 8 and 24 hours. Secondary outcomes included resolution of acidosis, adverse events and mortality. RESULTS 61 children were enrolled: 41 had shock and severe dehydrating diarrhoea, 20 had presumptive septic shock; 69% had decompensated shock. By 8 hours response to volume resuscitation was poor with shock persisting in most children:-HSD/5D 15/22 (68%) and RL14/25 (52%), p = 0.39. Oliguria was more prevalent at 8 hours in the HSD/5D group, 9/22 (41%), compared to RL-3/25 (12%), p = 0.02. Mortality was high, HSD/5D-15/26(58%) and RL 13/29(45%); p = 0.42. Most deaths occurred within 48 hours of admission. Neither pulmonary oedema nor cardiogenic failure was detected. CONCLUSIONS Outcome was universally poor characterised by persistence of shock, oliguria and high case fatality. Isotonic fluid was associated with modest improvement in shock and survival when compared to HSD/5D but inconclusive due to the limitations of design and effectiveness of either resuscitation strategy. Although isotonic fluid resuscitation did not result in cardiogenic heart failure, as previously feared, we conclude that the modest volumes used and rate of infusion were insufficient to promptly correct shock. The adverse performance of the recommended fluid resuscitation guideline for severe malnutrition should prompt clinical investigation of isotonic fluids for resuscitation of compensated shock, defining rate and volumes required to inform future guidelines. TRIAL REGISTRATION The trial is registered as ISCRTN: 61146418.
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Affiliation(s)
- Samuel O Akech
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Japhet Karisa
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Phellister Nakamya
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Mwanamvua Boga
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Kathryn Maitland
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, UK
- Wellcome Trust Centre for Clinical Tropical Medicine, Imperial College, London, UK
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Al-Mubarak L, Al-Khenaizan S, Al Goufi T. Cutaneous presentation of kwashiorkor due to infantile Crohn's disease. Eur J Pediatr 2010; 169:117-9. [PMID: 19352699 DOI: 10.1007/s00431-009-0981-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Accepted: 03/24/2009] [Indexed: 11/29/2022]
Abstract
Kwashiorkor is one of the severe forms of protein-energy malnutrition. Many characteristic dermatoses can be seen in children suffering from kwashiorkor, and some are pathognomonic. Here, we report an infant who presented with diarrhea and skin signs of kwashiorkor, and duodenal biopsy was consistent with Crohn's disease. The patient was treated with prednisolone administered orally in a tapering course plus azathioprine, in addition to nutritional supplementation. The general condition of the patient quickly improved and his skin lesions completely resolved within 2 weeks. Kwashiorkor is a serious potentially fatal disease that occurs less often in developed countries leading to low index of suspicion by physicians and pediatricians in those regions. Occasionally, dermatologists have the rare chance of alerting pediatricians to the diagnosis of kwashiorkor, thus making a difference in the care of this disease.
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Affiliation(s)
- Luluah Al-Mubarak
- Division of Dermatology, Department of Medicine, King Saud Bin Abdulaziz University, King Fahad National Guard Hospital, King Abdulaziz Medical City, P.O. Box 22490, Riyadh 11426, Kingdom of Saudi Arabia
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Kamalu BP. Cassava (Manihot esculenta crantz) in the aetiology of kwashiorkor. Nutr Res Rev 2009; 6:121-35. [PMID: 19094305 DOI: 10.1079/nrr19930009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- B P Kamalu
- Department of Veterinary Pathology and Microbiology, University of Nigeria, Nsukka, Nigeria
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Manary MJ, Heikens GT, Golden M. Kwashiorkor: more hypothesis testing is needed to understand the aetiology of oedema. Malawi Med J 2009; 21:106-7. [PMID: 20345018 PMCID: PMC3717490 DOI: 10.4314/mmj.v21i3.45630] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Mark J Manary
- Department of Pediatrics, Washington University School of Medicine, USA
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Savadogo L, Zoetaba I, Donnen P, Hennart P, Sondo BK, Dramaix M. [Management of severe acute malnutrition in an urban nutritional rehabilitation center in Burkina Faso]. Rev Epidemiol Sante Publique 2007; 55:265-74. [PMID: 17590552 DOI: 10.1016/j.respe.2007.05.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2006] [Accepted: 03/20/2007] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Management of acute severe malnutrition greatly contributes to the reduction of childhood mortality rate. In developing countries, where malnutrition is common, number of acute severe malnutrition cases exceeds inpatient treatment capacity. Recent success of community-based therapeutic care put back on agenda the management of acute severe malnutrition. We analysed key issues of inpatient management of severe malnutrition to suggest appropriate global approach. METHODS Data of 1322 malnourished children, admitted in an urban nutritional rehabilitation center, in Burkina Faso, from 1999 to 2003 were analyzed. The nutritional status was assessed using anthropometrics indexes. Association between mortality and variables was measured by relative risks. Kaplan-Meier survival curves and Cox model were used. RESULTS From the 1322 hospitalized children, 8.5% dropped out. Daily weight gain was 10.18 (+/-7.05) g/kg/d. Among hospitalized malnourished children, 16% died. Patients were at high risk of early death, as 80% of deaths occurred during the first week. The risk of dying was highest among the severely malnourished: weight-for-height<-4 standard deviation (SD), RR=2.55 P<0,001; low MUAC-for-age, RR=2.05 P<0.001. Kaplan-Meier survival curves and Cox model showed that the variables most strongly associated with mortality were weight-for-height and MUAC-for-age. Among children discharged from the nutritional rehabilitation centre, 10.9% had weight-for-height<-3 SD. CONCLUSION The nutrition rehabilitation centre is confronted with extremely ill children with high risk of death. There is need to support those units for appropriate management of acute severe malnutrition. It is also important to implement community-based therapeutic care for management of children still malnourished at discharge from nutritional rehabilitation centre. These programs will contribute to reduce mortality rate and number of severely malnourished children attending inpatient nutrition rehabilitation centers, by prevention and early management.
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Affiliation(s)
- L Savadogo
- Département de biostatistique, école de santé publique, CP 598, université libre de Bruxelles, Bruxelles, Belgium.
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Abstract
Heikens discusses a new study published inPLoS Medicine that is helpful in reconsidering the applicability of the WHO treatment guidelines.
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Affiliation(s)
- Geert Tom Heikens
- Department of Paediatrics and Child Health, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi.
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Abstract
Severe acute malnutrition (SAM) is defined as a weight-for-height measurement of 70% or less below the median, or three SD or more below the mean National Centre for Health Statistics reference values, the presence of bilateral pitting oedema of nutritional origin, or a mid-upper-arm circumference of less than 110 mm in children age 1-5 years. 13 million children under age 5 years have SAM, and the disorder is associated with 1 million to 2 million preventable child deaths each year. Despite this global importance, child-survival programmes have ignored SAM, and WHO does not recognise the term "acute malnutrition". Inpatient treatment is resource intensive and requires many skilled and motivated staff. Where SAM is common, the number of cases exceeds available inpatient capacity, which limits the effect of treatment; case-fatality rates are 20-30% and coverage is commonly under 10%. Programmes of community-based therapeutic care substantially reduce case-fatality rates and increase coverage rates. These programmes use new, ready-to-use, therapeutic foods and are designed to increase access to services, reduce opportunity costs, encourage early presentation and compliance, and thereby increase coverage and recovery rates. In community-based therapeutic care, all patients with SAM without complications are treated as outpatients. This approach promises to be a successful and cost-effective treatment strategy.
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Oyelami OA, Maxwell SM, Adelusola KA, Aladekoma TA, Oyelese AO. Aflatoxins in the lungs of children with kwashiorkor and children with miscellaneous diseases in Nigeria. JOURNAL OF TOXICOLOGY AND ENVIRONMENTAL HEALTH 1997; 51:623-8. [PMID: 9242232 DOI: 10.1080/00984109708984048] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Autopsy lung specimens from 20 children with kwashiorkor and 20 with other miscellaneous diseases, at the Obafemi Awolowo Teaching Hospital complex, Ile-Ife, Nigeria, were analyzed for the presence of aflatoxin using high-performance liquid chromatography. Aflatoxins were detected in 18 children who died from kwashiorkor but only in 13 of those who died from miscellaneous diseases. Of the 10 children, 5 in each group, who died with pneumonia, all had detectable levels of aflatoxins in their lungs. The two children with congestive cardiac failure, one secondary to pneumonia and the other secondary to tuberculous pericarditis, had more than two detectable aflatoxins in their lungs. These findings demonstrate that Nigerian children are exposed to aflatoxins and that high levels can accumulate in lung tissue.
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Affiliation(s)
- O A Oyelami
- Department of Pediatrics, Obafemi Awolowo University, Ile-Ife, Nigeria
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20
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Abstract
BACKGROUND Kwashiorkor is an edimatous form of severe malnutrition and is the predominant form of childhood malnutrition in Malawi. Potassium depletion is common and contributes to the high mortality. The aim of this study was to determine if high potassium supplementation improves the outcome of kwashiorkor treatment. METHODS We performed a randomised, double-blind, placebo-controlled, clinical trial of high potassium supplementation in 99 children with kwashiorkor. Controls (n = 51) received a standard potassium intake of 4.7 mmol/kg/day. The intervention group (n = 48) received 7.7 mmol/kg/day. All cases (intervention and control groups) were treated in the hospital-based Nutrition Rehabilitation Center and received a standard treatment regime of mild feeds, mineral and vitamin supplements, and antibiotics. RESULTS There was no significant difference in length of hospitalization, or time for resolution of oedema between groups. The case-fatality rate was reduced by 33% in the high potassium intervention group (13/48) compared to controls (21/51). There was a significant reduction in late deaths (13 in controls vs 3 in intervention group; odds ratio 5.3, 95% confidence interval 1.2-31.0) but no difference in early deaths (0-5 days). The intervention group also had significantly fewer presumed septic episodes (3 vs 18, odds ratio 8.9, confidence interval 2.2-50.9), respiratory symptoms, and new skin ulcerations than controls. CONCLUSIONS The high potassium supplementation reduced mortality and significant morbidity in kwashiorkor. This may be due to improved myocardial and immune function from earlier repletion of intracellular potassium. We recommend that the standard potassium supplement for the initial phase of treatment of kwashiorkor be increased from 4 to 8 mmol/kg/day.
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Affiliation(s)
- M J Manary
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
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21
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Braunschweig CL, Sowers M, Kovacevich DS, Hill GM, August DA. Parenteral zinc supplementation in adult humans during the acute phase response increases the febrile response. J Nutr 1997; 127:70-4. [PMID: 9040547 DOI: 10.1093/jn/127.1.70] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
The acute phase response (APR) that follows injury or infection is characterized by a decrease in serum zinc concentrations, which we hypothesized benefits the host. Additionally, we proposed that preventing this decline by supplementing zinc would result in an exaggerated APR as indicated by elevated temperatures, increased serum cytokine concentrations, interleukin 6 and the acute phase protein (ceruloplasmin). A prospective, randomized, double-blinded, clinical trial was conducted. Patients on home parenteral nutrition with a diagnosis of catheter sepsis and patients with a diagnosis of pancreatitis, also on total parenteral nutrition (TPN), were recruited for the study. Following enrollment, block randomization was used to assign patients to receive 0 mg (n = 23) or 30 mg (n = 21) of zinc per day for the first 3 d of TPN. Blood samples for measurement of serum zinc, copper, ceruloplasmin and interleukin-6 were obtained upon enrollment and on d 1 through 3 of TPN. The highest temperatures reported on these days in the medical record were also recorded. Repeated measures ANOVA was used to determine differences in the primary outcome variables over time. No significant differences between groups were observed in serum interleukin-6 or ceruloplasmin concentrations. A significantly higher (P = 0.035) temperature was observed in the zinc-supplemented group compared with the control group on d 3 of parenteral nutrition. We conclude that parenteral zinc supplementation in patients experiencing a mild APR resulted in an exaggerated APR as evidenced by a significantly higher febrile response.
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Affiliation(s)
- C L Braunschweig
- Department of Human Nutrition and Dietetics (M/C 517), University of Illinois at Chicago 60612-7256, USA
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Oyelami OA, Maxwell SM, Adeoba E. Aflatoxins and ochratoxin A in the weaning food of Nigerian children. ANNALS OF TROPICAL PAEDIATRICS 1996; 16:137-40. [PMID: 8790677 DOI: 10.1080/02724936.1996.11747816] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A total of 48 samples of maize-based gruels, used as weaning food for children, were taken daily from hospital meals and from patients' mothers while their children were on admission at the Wesley Guild Hospital, Ilesha, Nigeria. These samples were analysed for aflatoxins and ochratoxin A. Twelve samples (25%) were positive for aflatoxins (concentration range 2-19,716 pg/g) but only four (8%) were positive for ochratoxin (concentration range 142-6516 pg/g). In the majority, the concentrations were relatively low, only two having aflatoxin and one ochratoxin A levels greater than 1000 pg/g. It is concluded that, unlike aflatoxin, ochratoxin A contamination is unlikely to present a major health hazard to the newly weaned child in this area of Nigeria.
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Affiliation(s)
- O A Oyelami
- Department of Paediatrics and Child Health, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
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23
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Abstract
Brain function in 10 severely malnourished children and matched controls was assessed using spectral analysis of electroencephalographic responses to photic driving during slow-wave sleep. The percentage power in the classical EEG broad-band domains was derived from temporo-occipital records. The malnourished group (5-23 months old; z-score height-for-age -3.2 +/- 0.3, weight-for-height -2.5 +/- 0.3) were tested on admission and on discharge from hospital. No significant differences were found between admission and discharge. Significant differences were found between malnourished and control groups, in the alpha 1 band in the undriven EEG, and in the alpha/beta 1 power ratio while driving at 8 Hz. These electrophysiological abnormalities, persisting despite somatic rehabilitation, must be associated with the chronic rather than the acute aspects of malnutrition, and can index the deviation of brain function from normality.
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Affiliation(s)
- S Robinson
- Tropical Metabolism Research Unit, University of the West Indies, Mona, Jamaica
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24
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Courtright P, Canner J. The distribution of kwashiorkor in the southern region of Malawi. ANNALS OF TROPICAL PAEDIATRICS 1995; 15:221-6. [PMID: 8534041 DOI: 10.1080/02724936.1995.11747776] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Using existing nutritional survey data collected over an 11-month period during the recent drought, we sought to determine the distribution of kwashiorkor in the ten districts of the Southern Region of Malawi. Sampling and survey methods were identical and considerable efforts were made to ensure comparability. In 23 surveys, 25,824 children were weighed and measured and oedema was recorded. The district-adjusted prevalence of kwashiorkor was 18/1000. The northernmost districts of the Southern Region had rates five to ten times higher than the southernmost districts. Prevalence peaked at 18-23 months and was similar in boys and girls. Dysentery was associated with the presence of kwashiorkor while diarrhoea was not. The distinctive pattern of kwashiorkor in the region suggests that there are characteristics specific to the northern districts that place children in these areas at greater risk of kwashiorkor.
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Oyelami OA, Maxwell SM, Aladekomo TA, Adelusola KA. Two unusual cases of kwashiorkor: can protein deficiency explain the mystery? ANNALS OF TROPICAL PAEDIATRICS 1995; 15:217-9. [PMID: 8534040 DOI: 10.1080/02724936.1995.11747775] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Two children with unusual features of kwashiorkor are reported. One, an exclusively breastfed 7-month-old girl, had been admitted earlier, treated for pneumonia and discharged 3 weeks before she presented with kwashiorkor. The other was an identical twin who was admitted for kwashiorkor and gastro-enteritis. The twin sister was underweight but relatively well. Both children died. Potent aflatoxins were detected in the organs of these children on post-mortem examination. The occurrence of kwashiorkor in a fully breastfed infant and in an identical twin does not accord with the extant belief that the aetiology of kwashiorkor is wholly nutritional, but suggests a disease probably of multifactorial origin.
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Affiliation(s)
- O A Oyelami
- Department of Paediatrics and Child Health, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
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26
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Donzelli GP, Rapisardi G, Moroni M, Zani S, Tomasini B, Ismaelli A, Bruscaglioni P. Computerized cry analysis in infants affected by severe protein energy malnutrition. Acta Paediatr 1994; 83:204-11. [PMID: 8193504 DOI: 10.1111/j.1651-2227.1994.tb13052.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
A new method of computerized cry analysis has been utilized to evaluate the cries of infants affected by severe protein energy malnutrition. We studied 17 Kenian babies affected by severe malnutrition for more than four months (9 cases of marasmus and 8 of kwashiorkor) and a control group of 17 well-nourished babies. The cries of the malnourished children showed lower inter-utterance variability, formants' frequencies and cry score, assigned by the Infant Cry Modulation Assessment Scale. The melodic pattern was more often flat, rising or falling-rising, when compared to the cries of the well-nourished babies. We hypothesize that these differences reflect the state of brain damage associated with protein energy malnutrition. No differences were found between the cries of infants affected by marasmus and those affected by kwashiorkor, between the cries recorded before and after nutritional therapy and between the first cries of malnourished children who subsequently died during hospitalization and those of infants who survived.
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Affiliation(s)
- G P Donzelli
- Department of Paediatrics, NICU, A Meyer Hospital, Florence, Italy
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27
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Stanfield JP. Some aspects of the long-term effects of malnutrition on the behaviour of children in the Third World. Proc Nutr Soc 1993; 52:201-10. [PMID: 8493266 DOI: 10.1079/pns19930052] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Abstract
In a study of the pathogenesis of the oedema of kwashiorkor the ultrastructure of the kidneys from 6 children was examined shortly after they died from oedematous malnutrition. There was a generalised effacement of the glomerular epithelial cells onto the basement membrane. The filtration slits that remained were narrowed. The picture was similar to that seen in minimal-change nephrotic syndrome--but none of the children had albuminuria. The degree of effacement was statistically related to treatment with gentamicin. The findings suggest that there is a defect in the anionic charge of the glomerular basement membrane in oedematous malnutrition, that the membrane charge is more easily neutralised by cations such as gentamicin, and that, because proteinuria is not a feature of oedematous malnutrition, the proteinuria in other conditions associated with glomerular epithelial cell effacement (eg, minimal-change nephrotic syndrome) is due to something more complex than simple loss of charge.
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Affiliation(s)
- M H Golden
- Tropical Metabolism Research, University of the West Indies, Mona, Kingston 7, Jamaica
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