RESUMEN
In developing countries, more than 12 million children die each year from the combined effects of malnutrition and infection. Malnourished children have impaired cellular immunity and are particularly sensitive to opportunistic infections. However, immune recovery has rarely been investigated during nutritional rehabilitation. Indeed, mortality remains high during renutrition, and relapses are frequent. We established a center in Cochabamba, Bolivia, specifically to save these children by treating both clinical and nutritional problems and restoring immune function. The CRIN (center for immuno-nutritional recovery) admits children with severe malnutrition from the Cochabamba suburban area. They are from low income families, in crowded living conditions with poor sanitation and are weaned early. Nutritional diagnosis was based on weight-for-height, arm to head circumference ratio and clinical examination for edema, loss of subcutaneous tissue and diminished muscle mass. The children were examined daily, and first treated for respiratory and intestinal infections. Sociological and psychological aspects were also included in our holistic approach to treating severe malnutrition. Children received a four-stage diet lasting 2 months. During the initial phase (1 week) they were given an oil-sugar-milk based diet, with half lactose concentration, seven times a day. This supplied 1.5 to 2.5 g of protein and 120 to 150 kcal/kg of body weight, according to the PEM pattern. Protein and energy intake was then slowly increased during the transition phase (1 week). During the next, 'calorific-protein bombing' phase (6 weeks) 5 g of protein and 200 kcal/kg of body weight were given daily, such that there was sufficient energy for protein accumulation. During the last, discharge phase (1 week), the protein and energy contents were slowly decreased. Weight, height, arm and head circumferences, and triceps skin-fold thickness were measured weekly by standardized methods. Thymus size was assessed weekly by mediastinal ultrasound scanning with a portable scanner (ALOKA SSD-210 DXII, Tokyo) using a 5 MHz linear pediatric probe. Lymphocyte subpopulations in peripheral blood were investigated monthly using monoclonal antibodies. Compared to controls, the malnourished group had severe involution of the thymus, a significantly higher proportion of circulating immature T lymphocytes and a lower proportion of mature T lymphocytes. The two month longitudinal study showed that normal anthropometric values (90% NCHS weight for height) were recovered after one month of rehabilitation. However, immune recovery (thymic area of 350 nm2) required two months. This may explain the frequent relapses among malnourished children discharged after one month on the basis of 'apparent nutritional health'. Such children may remain immunodepressed, and should therefore be considered as high risk children. To test an immunostimulatory treatment, we designed a historical cohort study of malnourished children who received 2 mg of zinc per day. The children were matched for age, sex, anthropometric criteria and nutritional status with malnourished control children (treated previously with zinc). Anthropometric recovery was obtained in both groups in one month. Children receiving zinc attained immunological recovery within one month, whereas children not receiving zinc took two months. Thus zinc hastened immunological recovery concomitant with nutritional recovery such that the duration of hospitalization could be halved: after one month of this immuno-nutritional treatment, malnourished children appear to be sufficiently healthy to face their pathogenic home environment.
Asunto(s)
Adyuvantes Inmunológicos/uso terapéutico , Huésped Inmunocomprometido , Trastornos Nutricionales/terapia , Adyuvantes Inmunológicos/administración & dosificación , Animales , Antropometría , Bolivia , Niño , Preescolar , Estudios de Cohortes , Países en Desarrollo , Grasas de la Dieta/administración & dosificación , Proteínas en la Dieta/administración & dosificación , Sacarosa en la Dieta/administración & dosificación , Ingestión de Energía , Femenino , Humanos , Inmunidad Celular , Lactante , Enfermedades Intestinales/microbiología , Enfermedades Intestinales/terapia , Lactosa/administración & dosificación , Estudios Longitudinales , Masculino , Leche , Trastornos Nutricionales/dietoterapia , Trastornos Nutricionales/inmunología , Infecciones del Sistema Respiratorio/terapia , Salud Suburbana , Timo/inmunología , Timo/patología , Zinc/administración & dosificación , Zinc/uso terapéuticoRESUMEN
A questionnaire was devised to assess changes in the quality of life of insomniac patients when treated by a hypnotic. The questionnaire was validated in two groups of patients (60 non-insomniac and 52 insomniac patients). The results of this study confirmed the relevance of the questionnaire and its power to distinguish between the two groups of patients. A second study carried out simultaneously in 58 insomniac patients receiving treatment showed the internal reliability of the questionnaire and its reproducibility after 3 to 5 days.
RESUMEN
This work investigates how thymic dysfunction contributes to the depression of cell-mediated immunity in protein-energy malnutrition (PEM). In Bolivian children hospitalized for severe PEM, the size of the thymus was measured by echography, and the lymphocyte subpopulations were detected by using monoclonal antibodies. These data were compared with those obtained from healthy control subjects. Regardless of the clinical form of PEM, our results show a high degree of T lymphocyte immaturity in severely malnourished children, which correlates with a severe involution of the thymus. Before in vitro incubation with thymulin, this significant increase in the percentage of circulating immature T lymphocytes was concomitant with a decrease in mature T lymphocytes and a slight increase in cytotoxic T subpopulations. After in vitro incubation with thymulin, immature T lymphocytes decreased and mature T lymphocytes increased.
Asunto(s)
Kwashiorkor/inmunología , Subgrupos Linfocitarios/efectos de los fármacos , Desnutrición Proteico-Calórica/inmunología , Factor Tímico Circulante/farmacología , Antropometría , Vacuna BCG/inmunología , Preescolar , Recuento de Eritrocitos , Femenino , Hemoglobinas/análisis , Humanos , Hipersensibilidad Tardía , Inmunidad Celular , Lactante , Kwashiorkor/sangre , Kwashiorkor/patología , Recuento de Leucocitos , Masculino , Desnutrición Proteico-Calórica/sangre , Desnutrición Proteico-Calórica/patología , Timo/patologíaRESUMEN
Protein-energy malnutrition (PEM) leads to an immune deficiency, which is now well documented. Some investigators have suggested that the associated zinc deficiency is important in thymic involution and changes in cellular immunity. To evaluate the respective roles of nutritional deficiency, infection, and zinc in the alteration of thymic function, we measured the amounts of thymulin (facteur thymic serique, or FTS) and of Zn in the thymus glands of 58 Senegalese children who died in various stages of malnutrition. In the severe forms (marasmus, kwashiorkor, and marasmic kwashiorkor) the thymus was tiny and contained very little thymulin. The Zn content of the thymus was high whatever the nutritional state of the subject and was related significantly only to the presence of infections. In Senegalese children thymic atrophy and depleted thymulin content are associated with severe PEM but not systemic infection or depleted thymic Zn content.