<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Malnutrition and can you explain it in depth? [/INST] Malnutrition occurs when an organism gets too few or too many nutrients, resulting in health problems. Specifically, it is "a deficiency, excess, or imbalance of energy, protein and other nutrients" which adversely affects the bodys tissues and form.Malnutrition is a category of diseases that includes undernutrition and overnutrition. Undernutrition is a lack of nutrients, which can result in stunted growth, wasting, and underweight. A surplus of nutrients causes overnutrition, which can result in obesity. In some developing countries, overnutrition in the form of obesity is beginning to appear within the same communities as undernutrition.Most clinical studies use the term malnutrition to refer to undernutrition. However, the use of malnutrition instead of undernutrition makes it impossible to distinguish between undernutrition and overnutrition, a less acknowledged form of malnutrition. Accordingly, a 2019 report by The Lancet Commission suggested expanding the definition of malnutrition to include "all its forms, including obesity, undernutrition, and other dietary risks." The World Health Organization and The Lancet Commission have also identified "[t]he double burden of malnutrition," which occurs from "the coexistence of overnutrition (overweight and obesity) alongside undernutrition (stunted growth and wasting)."

Prevalence
It is estimated that nearly one in three persons globally has at least one form of malnutrition: wasting, stunting, vitamin or mineral deficiency, overweight, obesity, or diet-related noncommunicable diseases. Undernutrition is more common in developing countries. Stunting is more prevalent in urban slums than in rural areas. Studies on malnutrition have the population categorised into different groups including infants, under-five children, children, adolescents, pregnant women, adults and the elderly population. The use of different growth references in different studies leads to variances in the undernutrition prevalence reported in different studies. Some of the growth references used in studies include the
National Center for Health Statistics (NCHS) growth charts, WHO reference 2007, Centers for Disease Control and Prevention (CDC) growth charts, National Health and Nutrition Examination Survey (NHANES), WHO reference 1995, Obesity Task Force (IOTF) criteria and Indian Academy of Pediatrics (IAP) growth charts.

In children
The prevalence of undernutrition is highest among children under five. In 2020, 149 million children under five years old were stunted, 45 million were wasted, and 38.9 million were overweight or obese. The following year, an estimated 45% of deaths in children were linked to undernutrition. The prevalence of wasting among children under five in South Asia was reported to be 16% moderately or severely wasted. In Asia, India has one of the highest burden of wasting with over 20% wasted children. However, the burden of undernutrition among under-five children in African countries is much higher. A pooled analysis of the prevalence of chronic undernutrition among under-five children in East Africa was identified to be 33.3%. This prevalence of undernutrition among under-five children ranged from 21.9% in Kenya to 53% in Burundi. In Tanzania, the prevalence of stunting, among children under five varied from 41% in lowland and 64.5% in highland areas. Undernutrition by underweight and wasting was 11.5% and 2.5% in lowland and 22.% and 1.4% in the highland areas of Tanzania respectively. In South Sudan, the prevalence of undernutrition explained by stunting, underweight and wasting in under-five children were 23.8%, 4.8% and 2.3% respectively.Vitamin A deficiency affects one third of children under age 5 around the world, leading to 670,000 deaths and 250,000–500,000 cases of blindness.

In adults
As of June 2021, 1.9 billion adults were overweight or obese, and 462 million adults were underweight. Globally, two billion people had iodine deficiency in 2017. In 2020, 900 million women and children had anemia, which is often caused by iron deficiency.Certain groups have higher rates of undernutrition, including elderly people and women (in particular while pregnant or breastfeeding children under five years of age). Undernutrition is an increasing health problem in people aged over 65 years, even in developed countries, especially among nursing home residents and in acute care hospitals. In the elderly, undernutrition is more commonly due to physical, psychological, and social factors, not a lack of food. Age-related reduced dietary intake due to chewing and swallowing problems, sensory decline, depression, imbalanced gut microbiome, poverty and loneliness are major contributors to undernutrition in the elderly population.

Recent increase
There has been an increase in world hunger over the past decade. In 2015, 795 million people (about one in ten people on earth) had undernutrition. In 2020, one in nine people in the world—or 820 million people worldwide—was hungry.These increases are partially related to the ongoing COVID-19 pandemic, which continues to highlight the weaknesses of current food and health systems. It has contributed to food insecurity, increasing hunger worldwide; meanwhile, lower physical activity during lockdowns has contributed to increases in overweight and obesity. In 2020, experts estimated that by the end of the year, the pandemic could double the number of people at risk of suffering acute hunger. Similarly, experts estimate that the prevalence of moderate and severe wasting could increase by 14% due to COVID-19; coupled with reductions in nutrition and health services coverage, this could result in over 128,000 additional deaths among children under 5 in 2020 alone. Although COVID-19 is less severe in children than in adults, the risk of severe disease increases with undernutrition.Other major causes of hunger include manmade conflicts, climate changes, and economic downturns.

Definitions
Undernutrition
Undernutrition can occur either due to protein-energy wasting or as a result of micronutrient deficiencies. It adversely affects physical and mental functioning, and causes changes in body composition and body cell mass. Undernutrition is a major health problem, causing the highest mortality rate in children, and is responsible for long-lasting physiologic effects. It is a barrier to the complete physical and mental development of children.Undernutrition can manifest as stunting, wasting, and underweight. If undernutrition occurs during pregnancy, or before two years of age, it may result in permanent problems with physical and mental development. Extreme undernutrition can cause starvation, chronic hunger, Severe Acute Malnutrition (SAM), and/or Moderate Acute Malnutrition (MAM).
The signs and symptoms of micronutrient deficiencies depend on which micronutrient is lacking. However, undernourished people are often thin and short, with very poor energy levels; and swelling in the legs and abdomen is also common. People who are undernourished often get infections and frequently feel cold.

Micronutrient malnutrition
Micronutrient malnutrition results from inadequate intake of vitamins and minerals. Worldwide, deficiencies in iodine, Vitamin A, and iron are the most common. Children and pregnant women in low-income countries are at especially high risk for micronutrient deficiencies.Anemia is most commonly caused by iron deficiency, but can also result from other micronutrient deficiencies and diseases. This condition can have major health consequences.It is possible to have overnutrition simultaneously with micronutrient deficiencies; this condition is termed the double burden of malnutrition.

Protein-energy malnutrition
Undernutrition sometimes refers specifically to protein–energy malnutrition (PEM). This condition involves both micronutrient deficiencies and an imbalance of protein intake and energy expenditure. It differs from calorie restriction in that calorie restriction may not result in negative health effects. Hypoalimentation (underfeeding) is one cause of undernutrition.Two forms of PEM are kwashiorkor and marasmus; both commonly coexist.

Kwashiorkor is primarily caused by inadequate protein intake. Its symptoms include edema, wasting, liver enlargement, hypoalbuminaemia, and steatosis; the condition may also cause depigmentation of skin and hair. The disorder is further identified by a characteristic swelling of the belly, which disguises the patients undernourished condition. Kwashiorkor means displaced child and is derived from the Ga language of coastal Ghana in West Africa. It means "the sickness the baby gets when the next baby is born," as it often occurs when the older child is deprived of breastfeeding and weaned to a diet composed largely of carbohydrates.Marasmus (meaning to waste away) can result from a sustained diet that is deficient in both protein and energy. This causes their metabolism to adapt in order to prolong survival. The primary symptoms are severe wasting, leaving little or no edema; minimal subcutaneous fat; and abnormal serum albumin levels. It is traditionally seen in cases of famine, significant food restriction, or severe anorexia. Conditions are characterized by extreme wasting of the muscles and a gaunt expression.

Overnutrition
Excessive consumption of energy-dense foods and drinks and limited physical activity causes overnutrition. It causes overweight, defined as a body mass index (BMI) of 25 or more, and can lead to obesity (a BMI of 30 or more). Obesity has become a major health issue worldwide. Overnutrition is linked to chronic non-communicable diseases like diabetes, certain cancers, and cardiovascular diseases. Hence identifying and addressing the immediate risk factors has become a major health priority. The recent evidence on the impact of diet-induced obesity in fathers and mothers around the time of conception is identified to negatively program the health outcomes of multiple generations.

Classifying malnutrition
Definition by Gomez & Galvan
In 1956, Gómez and Galvan studied factors associated with death in a group of undernourished children in a hospital in Mexico City, Mexico. They defined three categories of malnutrition: first, second, and third degree. The degree of malnutrition is calculated based on a childs body size compared to the median weight for their age. The risk of death increases with increasing degrees of malnutrition.An adaptation of Gomezs original classification is still used today. While it provides a way to compare malnutrition within and between populations, this classification system has been criticized for being "arbitrary" and for not considering overweight as a form of malnutrition. Also, height alone may not be the best indicator of malnutrition; children who are born prematurely may be considered short for their age even if they have good nutrition.

Definition by Waterlow
In the 1970s, John Conrad Waterlow established a new classification system for malnutrition. Instead of using just weight for age measurements, Waterlows system combines weight-for-height (indicating acute episodes of malnutrition) with height-for-age to show the stunting that results from chronic malnutrition. One advantage of the Waterlow classification is that weight for height can be calculated even if a childs age is unknown.
The World Health Organization frequently uses these classifications of malnutrition, with some modifications.

Effects
Malnutrition weakens every part of the immune system. Protein and energy malnutrition increases susceptibility to infection; so do deficiencies of specific micronutrients (including iron, zinc, and vitamins). In communities or areas that lack access to safe drinking water, these additional health risks present a critical problem.
Malnutrition plays a major role in the onset of active tuberculosis. It also raises the risk of HIV transmission from mother to child, and increases replication of the virus. Malnutrition can cause vitamin-deficiency-related diseases like scurvy and rickets. As malnutrition worsens, those affected have less energy and experience impairment in brain functions. This can make it difficult (or impossible) for them to perform the tasks needed to acquire food, earn an income, or gain an education.
Malnutrition can also cause acute problems, like hypoglycemia (low blood sugar). This condition can cause lethargy, limpness, seizures, and loss of consciousness. Children are particularly at risk and can become hypoglycemic after 4 to 6 hours without food. Dehydration can also occur in malnourished people, and can be life-threatening, especially in babies and small children.

Signs
There are many different signs of dehydration in malnourished people. These can include sunken eyes; a very dry mouth; decreased urine output and/or dark urine; increased heart rate with decreasing blood pressure; and altered mental status.

Cognitive development
Protein-calorie malnutrition can cause cognitive impairments. This most commonly occurs in people who were malnourished during a "critical period ... from the final third of gestation to the first 2 years of life". For example, in children under two years of age, iron deficiency anemia is likely to affect brain function acutely, and probably also chronically. Similarly, folate deficiency has been linked to neural tube defects.Iodine deficiency is "the most common preventable cause of mental impairment worldwide." "Even moderate [iodine] deficiency, especially in pregnant women and infants, lowers intelligence by 10 to 15 I.Q. points, shaving incalculable potential off a nations development." Among those affected, very few people experience the most visible and severe effects: disabling goiters, cretinism and dwarfism. These effects occur most commonly in mountain villages. However, 16 percent of the worlds people have at least mild goiter (a swollen thyroid gland in the neck)."

Causes & risk factors
Social and political
Social conditions have a significant influence on the health of people. The social determinants of undernutrition mainly include poor education, poverty, disease burden and lack of womens empowerment. Identifying and addressing these determinants can eliminate undernutrition in the long term. Identification of the social conditions that causes malnutrition in children under five has received significant research attention as it is a major public health problem.
Undernutrition most commonly results from a lack of access to high-quality, nutritious food. The household income is a socio-economic variable that influences the access to nutritious food and the probability of under and overnutrition in a community. In the study by Ghattas et al. (2020), the probability of overnutrition is significantly higher in higher-income families than in disadvantaged families. High food prices is a major factor preventing low income households from getting nutritious food  For example, Khan and Kraemer (2009) found that in Bangladesh, low socioeconomic status was associated with chronic malnutrition since it inhibited purchase of nutritious foods (like milk, meat, poultry, and fruits). Food shortages may also contribute to malnutritions in countries which lack technology. However, in the developing world, eighty percent of malnourished children live in countries that produce food surpluses, according to estimates from the Food and Agriculture Organization (FAO). The economist Amartya Sen observes that, in recent decades, famine has always been a problem of food distribution, purchasing power, and/or poverty, since there has always been enough food for everyone in the world.There are also sociopolitical causes of malnutrition. For example, the population of a community might be at increased risk for malnutrition if government is poor and the area lacks health-related services. On a smaller scale, certain households or individuals may be at an even higher risk due to differences in income levels, access to land, or levels of education. Community plays a crucial role in addressing the social causes of malnutrition. For example, communities with high social support and knowledge sharing about social protection programs can enable better public service demands. Better public service demands and social protection programs minimise the risk of malnutrition in these communities.
It is argued that commodity speculators are increasing the cost of food. As the real-estate bubble in the United States was collapsing, it is said that trillions of dollars moved to invest in food and primary commodities, causing the 2007–2008 food price crisis.The use of biofuels as a replacement for traditional fuels raises the price of food. The United Nations special rapporteur on the right to food, Jean Ziegler proposes that agricultural waste, such as corn cobs and banana leaves, should be used as fuel instead of crops.In some developing countries, overnutrition (in the form of obesity) is beginning to appear in the same communities where malnutrition occurs. Overnutrition increases with urbanisation, food commercialisation and technological developments and increases physical inactivity. Variations in the health status of individuals in the same society are associated with the societal structure and an individuals socioeconomic status which leads to income inequality, racism, educational differences and lack of opportunities.

Diseases & conditions
Infectious diseases which increase nutrient requirements, such as gastroenteritis, pneumonia, malaria, and measles, can cause malnutrition. So can some chronic illnesses, especially HIV/AIDS.Malnutrition can also result from abnormal nutrient loss due to diarrhea or chronic small bowel illnesses, like Crohns disease or untreated coeliac disease. "Secondary malnutrition" can result from increased energy expenditure.In infants, a lack of breastfeeding may contribute to undernourishment. Anorexia nervosa and bariatric surgery can also cause malnutrition.

Dietary practices
Undernutrition
Undernutrition due to lack of adequate breastfeeding is associated with the deaths of an estimated one million children annually. Illegal advertising of breast-milk substitutes contributed to malnutrition and continued three decades after its 1981 prohibition under the WHO International Code of Marketing Breast Milk Substitutes.Maternal malnutrition can also factor into the poor health or death of a baby. Over 800,000 neonatal deaths have occurred because of deficient growth of the fetus in the mothers womb.Deriving too much of ones diet from a single source, such as eating almost exclusively potato, maize or rice, can cause malnutrition. This may either be from a lack of education about proper nutrition, or from only having access to a single food source.It is not just the total amount of calories that matters but specific nutritional deficiencies such as vitamin A deficiency, iron deficiency or zinc deficiency can also increase risk of death.

Overnutrition
Overnutrition caused by overeating is also a form of malnutrition. In the United States, more than half of all adults are now overweight—a condition that, like hunger, increases susceptibility to disease and disability, reduces worker productivity, and lowers life expectancy. Overeating is much more common in the United States, since most people have adequate access to food. Many parts of the world have access to a surplus of non-nutritious food. Increased sedentary lifestyles also contribute to overnutrition. Yale University psychologist Kelly Brownell calls this a "toxic food environment," where fat- and sugar-laden foods have taken precedence over healthy nutritious foods.In these developed countries, overnutrition can be prevented by choosing the right kind of food. More fast food is consumed per capita in the United States than in any other country. This mass consumption of fast food results from its affordability and accessibility. Fast food, which is low in cost and nutrition, is high in calories. Due to increasing urbanization and automation, people are living more sedentary lifestyles. These factors combine to make weight gain difficult to avoid.Overnutrition also occurs in developing countries. It has appeared in parts of developing countries where income is on the rise. It is also a problem in countries where hunger and poverty persist. Economic development, rapid urbanisation and shifting dietary patterns have increased the burden of overnutrition in the cities of low and middle-income countries. In China, consumption of high-fat foods has increased, while consumption of rice and other goods has decreased.

Overeating leads to many diseases, such as heart disease and diabetes, that may be fatal.

Agricultural productivity
Local food shortages can be caused by a lack of arable land, adverse weather, and/or poorer farming skills (like inadequate crop rotation). They can also occur in areas which lack the technology or resources needed for the higher yields found in modern agriculture. These resources include fertilizers, pesticides, irrigation, machinery, and storage facilities. As a result of widespread poverty, farmers and governments cannot provide enough of these resources to improve local yields.
Additionally, the World Bank and some wealthy donor countries have pressured developing countries to use free market policies. Even as the United States and Europe extensively subsidized their own farmers, they urged developing countries to cut or eliminate subsidized agricultural inputs, like fertilizer. Without subsidies, few (if any) farmers in developing countries can afford fertilizer at market prices. This leads to low agricultural production, low wages, and high, unaffordable food prices. Fertilizer is also increasingly unavailable because Western environmental groups have fought to end its use due to environmental concerns. The Green Revolution pioneers Norman Borlaug and Keith Rosenberg cited as the obstacle to feeding Africa by .

Future threats
In the future, variety of factors could potentially disrupt global food supply and cause widespread malnutrition.
Global warming is of importance to food security. Almost all malnourished people (95%) live in the tropics and subtropics, where the climate is relatively stable. According to the latest Intergovernmental Panel on Climate Change reports, temperature increases in these regions are "very likely." Even small changes in temperatures can make extreme weather conditions occur more frequently. Extreme weather events, like drought, have a major impact on agricultural production, and hence nutrition. For example, the 1998–2001 Central Asian drought killed about 80 percent of livestock in Iran and caused a 50% reduction in wheat and barley crops there. Other central Asian nations experienced similar losses. An increase in extreme weather such as drought in regions such as Sub-Saharan Africa would have even greater consequences in terms of malnutrition. Even without an increase of extreme weather events, a simple increase in temperature reduces the productivity of many crop species, and decreases food security in these regions.Another threat is colony collapse disorder, a phenomenon where bees die in large numbers. Since many agricultural crops worldwide are pollinated by bees, colony collapse disorder represents a threat to the global food supply.

Prevention
Reducing malnutrition is key part of the United Nations Sustainable Development Goal 2 (SDG2), "Zero Hunger," which aims to reduce malnutrition, undernutrition, and stunted child growth. Managing severe acute undernutrition in a community setting has received significant research attention.

Food security
In the 1950s and 1960s, the Green Revolution aimed to bring modern Western agricultural techniques (like nitrogen fertilizers and pesticides) to Asia. Investments in agriculture, such as fund fertilizers and seeds, increased food harvests and thus food production. Consequently, food prices and malnutrition decreased (as they had earlier in Western nations).The Green Revolution was possible in Asia because of existing infrastructure and institutions, such as a system of roads and public seed companies that made seeds available. These resources were in short supply in Africa, decreasing the Green Revolutions impact on the continent.
For example, almost five million of the 13 million people in Malawi used to need emergency food aid. However, in the early 2000s, the Malawian government changed its agricultural policies, and implemented subsidies for fertilizer and seed introduced against World Bank strictures. By 2007, farmers were producing record-breaking corn harvests. Corn production leaped to 3.4 million in 2007 compared to 1.2 million in 2005, making Malawi a major food exporter. Consequently, food prices lowered and wages for farmworkers rose. Such investments in agriculture are still needed in other African countries like the Democratic Republic of the Congo (DRC). Despite the countrys great agricultural potential, the prevalence of malnutrition in the DRC is among the highest in the world. Proponents for investing in agriculture include Jeffrey Sachs, who argues that wealthy countries should invest in fertilizer and seed for Africas farmers.Imported Ready to Use Therapeutic Food (RUTF) has been used to treat malnutrition in northern Nigeria. Some Nigerians also use soy kunu, a locally sourced and prepared blend consisting of peanut, millet and soybeans.New technology in agricultural production has great potential to combat undernutrition. It makes farming easier, thus improving agricultural yields. By increasing farmers incomes, this could reduce poverty. It would also open up area which farmers could use to diversify crops for household use.
The World Bank claims to be part of the solution to malnutrition, asserting that countries can best break the cycle of poverty and malnutrition by building export-led economies, giving them the financial means to buy foodstuffs on the world market. The role of the World Bank cannot be overemphasized in the prevention of malnutrition..

Economics
Many aid groups have found that giving cash assistance (or cash vouchers) is more effective than donating food. Particularly in areas where food is available but unaffordable, giving cash assistance is a cheaper, faster, and more efficient way to deliver help to the hungry. In 2008, the UNs World Food Program, the biggest non-governmental distributor of food, announced that it would begin distributing cash and vouchers instead of food in some areas, which Josette Sheeran, the WFPs executive director, described as a "revolution" in food aid. The aid agency Concern Worldwide piloted a method of giving cash assistance using a mobile phone operator, Safaricom, which runs a money transfer program that allows cash to be sent from one part of a country to another.However, during a drought, delivering food might be the most appropriate way to help people, especially those who live far from markets and thus have limited access to them. Fred Cuny stated that "the chances of saving lives at the outset of a relief operation are greatly reduced when food is imported. By the time it arrives in the country and gets to people, many will have died." U.S. law requires food aid to be purchased at home rather than in the countries where the hungry live; this is inefficient because approximately half of the money spent goes for transport. Cuny further pointed out that "studies of every recent famine have shown that food was available in-country—though not always in the immediate food deficit area" and "even though by local standards the prices are too high for the poor to purchase it, it would usually be cheaper for a donor to buy the hoarded food at the inflated price than to import it from abroad."

Food banks and soup kitchens address malnutrition in places where people lack money to buy food. A basic income has been proposed as a way to ensure that everyone has enough money to buy food and other basic needs. This is a form of social security in which all citizens or residents of a country regularly receive an unconditional sum of money, either from a government or some other public institution, in addition to any income received from elsewhere.

Successful initiatives
Ethiopia pioneered a program that later became part of the World Banks prescribed method for coping with a food crisis. Through the countrys main food assistance program, the Productive Safety Net Program, Ethiopia provided rural residents who were chronically short of food a chance to work for food or cash. Foreign aid organizations like the World Food Program were then able to buy food locally from surplus areas to distribute in areas with a shortage of food. Aid organizations now view the Ethiopian program as a model of how to best help hungry nations.
Successful initiatives also include Brazils recycling program for organic waste, which benefits farmers, the urban poor, and the city in general. City residents separate organic waste from their garbage, bag it, and then exchange it for fresh fruit and vegetables from local farmers. This reduces the countrys waste while giving the urban poor a steady supply of nutritious food.

World population
Restricting population size is a proposed solution to malnutrition. Thomas Malthus argues that population growth can be controlled by natural disasters and by voluntary limits through "moral restraint." Robert Chapman suggests that government policies are a necessary ingredient for curtailing global population growth. The United Nations recognizes that poverty and malnutrition (as well as the environment) are interdependent and complementary with population growth. According to the World Health Organisation, "Family planning is key to slowing unsustainable population growth and the resulting negative impacts on the economy, environment, and national and regional development efforts". However, more than 200 million women worldwide lack adequate access to family planning services.
There are different theories about what causes famine. Some theorists, like the Indian economist Amartya Sen, believe that the world has more than enough resources to sustain its population. In this view, malnutrition is caused by unequal distribution of resources and under- or unutilized arable land. For example, Sen argues that "no matter how a famine is caused, methods of breaking it call for a large supply of food in the public distribution system. This applies not only to organizing rationing and control, but also to undertaking work programmes and other methods of increasing purchasing power for those hit by shifts in exchange entitlements in a general inflationary situation."

Food sovereignty
Food sovereignty is one suggested policy framework to resolve access issues. In this framework, people (rather than international market forces) have the right to define their own food, agricultural, livestock, and fishery systems. Food First is one of the primary think tanks working to build support for food sovereignty. Neoliberals advocate for an increasing role of the free market.

Health facilities
Another possible long-term solution to malnutrition is to increase access to health facilities in rural parts of the world. These facilities could monitor undernourished children, act as supplemental food distribution centers, and provide education on dietary needs. Similar facilities have already proven very successful in countries such as Peru and Ghana.

Breastfeeding
In 2016, estimates suggested that more widespread breastfeeding could prevent about 823,000 deaths annually of children under age 5. In addition to reducing infant deaths, breast milk provides an important source of micronutrients - which are clinically proven to bolster childrens immune systems - and provides long-term defenses against non-communicable and allergic diseases. Breastfeeding improves cognitive abilities in children, and correlates strongly with individual educational achievements. As previously noted, lack of proper breastfeeding is a major factor in child mortality rates, and is a primary determinant of disease development for children. The medical community recommends exclusively breastfeeding infants for 6 months, with nutritional whole food supplementation and continued breastfeeding up to 2 years or older for overall optimal health outcomes. Exclusive breastfeeding is defined as giving an infant only breast milk for six months as a source of food and nutrition. This means no other liquids, including water or semi-solid foods.

Barriers to breastfeeding
Breastfeeding is noted as one of the most cost-effective medical interventions benefiting child health. While there are considerable differences among developed and developing countries, there are universal determinants of whether a mother breastfeeds or uses formula; these include income, employment, social norms, and access to healthcare. Many newly made mothers face financial barriers; community-based healthcare workers have helped to alleviate these barriers, while also providing a viable alternative to traditional and expensive hospital-based medical care. Recent studies, based upon surveys conducted from 1995 to 2010, show that exclusive breastfeeding rates have risen globally, from 33% to 39%. Despite the growth rates, medical professionals acknowledge the need for improvement given the importance of exclusive breastfeeding.

21st century global initiatives
Starting around 2009, there was renewed international media and political attention focused on malnutrition. This resulted in part from spikes in food prices and the 2008 financial crisis. Additionally, there was an emerging consensus that combating malnutrition is one of the most cost-effective ways to contribute to development. This led to the 2010 launch of the UNs Scaling up Nutrition movement (SUN).In April 2012, a number of countries signed the Food Assistance Convention, the worlds first legally binding international agreement on food aid. The following month, the Copenhagen Consensus recommended that politicians and private sector philanthropists should prioritize interventions against hunger and malnutrition in order to maximize the effectiveness of aid spending. The Consensus recommended prioritizing these interventions ahead of any others, including the fights against malaria and AIDS.In June 2015, the European Union and the Bill & Melinda Gates Foundation launched a partnership to combat undernutrition, especially in children. The program was first implemented in Bangladesh, Burundi, Ethiopia, Kenya, Laos and Niger. It aimed to help these countries improve information and analysis about nutrition, enabling them to develop effective national nutrition policies.Also in 2015, the UNs Food and Agriculture Organization created a partnership aimed at ending hunger in Africa by 2025. The African Unions Comprehensive Africa Agriculture Development Programme (CAADP) provided the framework for the partnership. It includes a variety of interventions, including support for improved food production, a strengthening of social protection, and integration of the right to food into national legislation.The EndingHunger campaign is an online communication campaign whose goal is to raise awareness about hunger. The campaign has created viral videos depicting celebrities voicing their anger about the large number of hungry people in the world.
After the Millennium Development Goals expired in 2015, the Sustainable Development Goals became the main global policy focus to reduce hunger and poverty. In particular, Goal 2: Zero Hunger sets globally agreed-upon targets to wipe out hunger, end all forms of malnutrition, and make agriculture sustainable. The partnership Compact2025 develops and disseminates evidence-based advice to politicians and other decision-makers, with the goal of ending hunger and undernutrition by 2025. The International Food Policy Research Institute (IFPRI) led the partnership, with the involvement of UN organisations, non-governmental organizations (NGOs), and private foundations.

Treatment
Improving nutrition
Efforts to improve nutrition are some of the common forms of development aid. Interventions often promote breastfeeding in order to reduce rates of malnutrition and death in children. Some of these interventions have been successful. For example, interventions with commodities such as ready to use therapeutic foods, micronutrient intervention and vitamin supplementation were identified to significantly improve nutrition, reduce stunting and prevent diseases in communities with severe acute malnutrition. In young children, outcomes improve when children between six months and two years of age receive complementary food (in addition to breast milk). There is also good evidence that supports giving supplemental micronutrients to pregnant women and young children in the developing world.Sending food and money is a common form of development aid, aimed at feeding hungry people. Some strategies help people buy food within local markets. Simply feeding students at school is insufficient.Longer-term measures include improving agricultural practices, reducing poverty, and improving sanitation.

Identifying malnourishment
Measuring children is crucial to identifying malnourishment. In 2000, the United States Centers for Disease Control and Prevention (CDC) established the International Micronutrient Malnutrition Prevention and Control (IMMPaCt) program. It tested children for malnutrition by conducting a three-dimensional scan, using an iPad or a tablet. Its objective was to help doctors provide more efficient treatments. There may be some chance of error when using this method.A systematic review of 42 studies found that many approaches to mitigating acute malnutrition are equally effective; thus, intervention decisions can be based on cost-related factors. Overall, evidence for the effectiveness of acute malnutrition interventions is not robust. The limited evidence related to cost indicates that community and outpatient management of children with uncomplicated malnutrition may be the most cost-effective strategy.

Medical management
It is often possible to manage severe malnutrition within a persons home, using ready-to-use therapeutic foods. In people with severe malnutrition complicated by other health problems, treatment in a hospital setting is recommended. In-hospital treatment often involves managing low blood sugar, maintaining adequate body temperature, addressing dehydration, and gradual feeding.Routine antibiotics are usually recommended because malnutrition weakens the immune system, causing a high risk of infection. Additionally, broad spectrum antibiotics are recommended in all severely undernourished children with diarrhea requiring admission to hospital.A severely malnourished child who appears to have dehydration, but has not had diarrhea, should be treated as if they have an infection.Among malnourished people who are hospitalized, nutritional support improves protein intake, calorie intake, and weight.

Bangladeshi model
In response to child malnutrition, the Bangladeshi government recommends ten steps for treating severe malnutrition:
Prevent or treat dehydration
Prevent or treat low blood sugar
Prevent or treat low body temperature
Prevent or treat infection;
Correct electrolyte imbalances
Correct micronutrient deficiencies
Start feeding cautiously
Achieve catch-up growth
Provide psychological support
Prepare for discharge and follow-up after recovery

Therapeutic foods
Due in part to limited research on supplementary feeding, there is little evidence that this strategy is beneficial. A 2015 systematic review of 32 studies found that there are limited benefits when children under 5 receive supplementary feeding, especially among younger, poorer, and more undernourished children.However, specially formulated foods do appear to be useful in treating moderate acute malnutrition in the developing world. These foods may have additional benefits in humanitarian emergencies, since they can be stored for years, can be eaten directly from the packet, and do not have to be mixed with clean water or refrigerated. In young children with severe acute malnutrition, it is unclear if ready-to-use therapeutic food differs from a normal diet.Severely malnourished individuals can experience refeeding syndrome if fed too quickly. Refeeding syndrome can result regardless of whether food is taken orally or parenterally. It can present several days after eating with potentially fatal heart failure, dysrhythmias, and confusion.Some manufacturers have fortified everyday foods with micronutrients before selling them to consumers. For example, flour has been fortified with iron, zinc, folic acid, and other B vitamins like thiamine, riboflavin, niacin and vitamin B12. Baladi bread (Egyptian flatbread) is made with fortified wheat flour. Other fortified products include fish sauce in Vietnam and iodized salt.

Micronutrient supplementation
According to the World Bank, treating malnutrition - mostly by fortifying foods with micronutrients - improves lives more quickly than other forms of aid, and at a lower cost. After reviewing a variety of development proposals, The Copenhagen Consensus, a group of economists who reviewed a variety of development proposals, ranked micronutrient supplementation as its number-one treatment strategy.In malnourished people with diarrhea, zinc supplementation is recommended following an initial four-hour rehydration period. Daily zinc supplementation can help reduce the severity and duration of the diarrhea. Additionally, continuing daily zinc supplementation for ten to fourteen days makes diarrhea less likely to recur in the next two to three months.Malnourished children also need both potassium and magnesium. Within two to three hours of starting rehydration, children should be encouraged to take food, particularly foods rich in potassium like bananas, green coconut water, and unsweetened fresh fruit juice. Along with continued eating, many homemade products can also help restore normal electrolyte levels. For example, early during the course of a childs diarrhea, it can be beneficial to provide cereal water (salted or unsalted) or vegetable broth (salted or unsalted). If available, vitamin A, potassium, magnesium, and zinc supplements should be added, along with other vitamins and minerals.Giving base (as in Ringers lactate) to treat acidosis without simultaneously supplementing potassium worsens low blood potassium.

Treating diarrhea
Preventing dehydration
Food and drink can help prevent dehydration in malnourished people with diarrhea. Eating (or breastfeeding, among infants) should resume as soon as possible. Sugary beverages like soft drinks, fruit juices, and sweetened teas are not recommended as they may worsen diarrhea.Malnourished people with diarrhea (especially children) should be encouraged to drink fluids; the best choices are fluids with modest amounts of sugar and salt, like vegetable broth or salted rice water. If clean water is available, they should be encouraged to drink that too. Malnourished people should be allowed to drink as much as they want, unless signs of swelling emerge.
Babies can be given small amounts of fluids via an eyedropper or a syringe without the needle. Children under two should receive a teaspoon of fluid every one to two minutes; older children and adults should take frequent sips of fluids directly from a cup. After the first two hours, fluids and foods should be alternated, rehydration should be continued at the same rate or more slowly, depending on how much fluid the child wants and whether they are having ongoing diarrhea. Alternating between rehydration and food at this point is After the first two hours of rehydration it is recommended that to alternate between rehydration and food.If vomiting occurs, fluids can be paused for 5–10 minutes and then restarted more slowly. Vomiting rarely prevents rehydration, since fluids are still absorbed and vomiting is usually short-term.

Oral rehydration therapy
If prevention has failed and dehydration develops, the preferred treatment is rehydration through oral rehydration therapy (ORT). In severely undernourished children with diarrhea, rehydration should be done slowly, according to the World Health Organization.
Oral rehydration solutions consist of clean water mixed with small amounts of sugars and salts. These solutions help restore normal electrolyte levels, provide a source of carbohydrates, and help with fluid replacement.Reduced-osmolarity ORS is the current standard of care for oral rehydration therapy, with reasonably wide availability. Introduced in 2003 by WHO and UNICEF, reduced-osmolarity solutions contain lower concentrations of sodium and glucose than original ORS preparations. Reduced-osmolarity ORS has the added benefit of reducing stool volume and vomiting while simultaneously preventing dehydration. Packets of reduced-osmolarity ORS include glucose, table salt, potassium chloride, and trisodium citrate. For general use, each packet should be mixed with a liter of water. However, for malnourished children, experts recommend adding a packet of ORS to two liters of water, along with an extra 50 grams of sucrose and some stock potassium solution.People who have no access to commercially available ORS can make a homemade version using water, sugar, and table salt. Experts agree that homemade ORS preparations should include one liter (34 oz.) of clean water and 6 teaspoons of sugar; however, they disagree about whether they should contain half a teaspoon of table salt or a full teaspoon. Most sources recommend using half a teaspoon of salt per liter of water. However, people with malnutrition have an excess of body sodium. To avoid worsening this symptom, ORS for people with severe undernutrition should contain half the usual amount of sodium and more potassium.

Patients who do not drink may require fluids by nasogastric tube. Intravenous fluids are recommended only in those who have significant dehydration due to their potential complications, including congestive heart failure.

Low blood sugar
Hypoglycemia, whether known or suspected, can be treated with a mixture of sugar and water. If the patient is conscious, the initial dose of sugar and water can be given by mouth. Otherwise, they should receive glucose by intravenous or nasogastric tube. If seizures occur (and continue after glucose is given), rectal diazepam may be helpful. Blood sugar levels should be re-checked on two hour intervals.

Hypothermia
Hypothermia (dangerously low core body temperature) can occur in malnutrition, particularly in children. Mild hypothermia causes confusion trembling, and clumsiness; more severe cases can be fatal. Keeping malnourished children warm can prevent or treat hypothermia. Covering the child (including their head) in blankets is one method. Another method is to warm the child through direct skin-to-skin contact with their mother or father, then covering both parent and child.
Warming methods are usually most important at night. Prolonged bathing or prolonged medical exams can further lower body temperature and are not recommended for malnourished children at high risk of hypothermia.

Epidemiology
The figures provided in this section on epidemiology all refer to undernutrition even if the term malnutrition is used which, by definition, could also apply to too much nutrition.
The Global Hunger Index (GHI) is a multidimensional statistical tool used to describe the state of countries hunger situation. The GHI measures progress and failures in the global fight against hunger. The GHI is updated once a year. The data from the 2015 report shows that Hunger levels have dropped 27% since 2000. Fifty two countries remain at serious or alarming levels. In addition to the latest statistics on Hunger and Food Security, the GHI also features different special topics each year. The 2015 report include an article on conflict and food security.

People affected
The United Nations estimated that there were 821 million undernourished people in the world in 2017. This is using the UNs definition of undernourishment, where it refers to insufficient consumption of raw calories, and so does not necessarily include people who lack micro nutrients. The undernourishment occurred despite the worlds farmers producing enough food to feed around 12 billion people—almost double the current world population.Malnutrition, as of 2010, was the cause of 1.4% of all disability adjusted life years.

Mortality
Mortality due to malnutrition accounted for 58 percent of the total mortality in 2006: "In the world, approximately 62 million people, all causes of death combined, die each year. One in twelve people worldwide is malnourished and according to the Save the Children 2012 report, one in four of the worlds children are chronically malnourished. In 2006, more than 36 million died of hunger or diseases due to deficiencies in micronutrients".In 2010 protein-energy malnutrition resulted in 600,000 deaths down from 883,000 deaths in 1990. Other nutritional deficiencies, which include iodine deficiency and iron deficiency anemia, result in another 84,000 deaths. In 2010 malnutrition caused about 1.5 million deaths in women and children.According to the World Health Organization, malnutrition is the biggest contributor to child mortality, present in half of all cases. Six million children die of hunger every year. Underweight births and intrauterine growth restrictions cause 2.2 million child deaths a year. Poor or non-existent breastfeeding causes another 1.4 million. Other deficiencies, such as lack of vitamin A or zinc, for example, account for 1 million. Malnutrition in the first two years is irreversible. Malnourished children grow up with worse health and lower education achievement. Their own children tend to be smaller. Malnutrition was previously seen as something that exacerbates the problems of diseases such as measles, pneumonia and diarrhea, but malnutrition actually causes diseases, and can be fatal in its own right.

History
Hunger has been a perennial human problem. However, until the early 20th century, there was relatively little awareness of the qualitative aspects of malnutrition.
Throughout history, various peoples have known the importance of eating certain foods to prevent symptoms now associated with malnutrition. Yet such knowledge appears to have been repeatedly lost and then re-discovered. For example, the ancient Egyptians reportedly knew the symptoms of scurvy. Much later, in the 14th century, Crusaders sometimes used anti-scurvy measures - for example, ensuring that citrus fruits were planted on Mediterranean islands, for use on sea journeys. However, for several centuries, Europeans appear to have forgotten the importance of these measures. They rediscovered this knowledge in the 18th century, and by the early 19th century, the Royal Navy was issuing frequent rations of lemon juice to every crewman on their ships. This massively reduced scurvy deaths among British sailors, which in turn gave the British a significant advantage in the Napoleonic Wars. Later on in the 19th century, the Royal Navy replaced lemons with limes (unaware at the time that lemons are far more effective at preventing scurvy).According to historian Michael Worboys, malnutrition was essentially discovered, and the science of nutrition established, between World War I and World War II. Advances built on prior works like Casimir Funks 1912 formulisation of the concept of vitamins. Scientific study of malnutrition increased in the 1920s and 1930s, and grew even more common after World War II.
Non-governmental organizations and United Nations agencies began to devote considerable energy to alleviating malnutrition around the world. The exact methods and priorities for doing this tended to fluctuate over the years, with varying levels of focus on different types of malnutrition like Kwashiorkor or Marasmus; varying levels of concern on protein deficiency compared to vitamins, minerals and lack of raw calories; and varying priorities given to the problem of malnutrition in general compared to other health and development concerns. The green Revolution of the 1950s and 1960s saw considerable improvement in capability to prevent malnutrition.One of the first official global documents addressing Food security and global malnutrition was the 1948 Universal Declaration of Human Rights(UDHR). Within this document it stated that access to food was part of an adequate right to a standard of living. The Right to food was asserted in the International Covenant on Economic, Social and Cultural Rights, a treaty adopted by the United Nations General Assembly on December 16, 1966. The Right to food is a human right for people to feed themselves in dignity, be free from hunger, food insecurity, and malnutrition. As of 2018, the treaty has been signed by 166 countries, by signing states agreed to take steps to the maximum of their available resources to achieve the right to adequate food.
However, after the 1966 International Covenant the global concern for the access to sufficient food only became more present, leading to the first ever World Food Conference that was held in 1974 in Rome, Italy. The Universal Declaration on the Eradication of Hunger and Malnutrition was a UN resolution adopted November 16, 1974 by all 135 countries that attended the 1974 World Food Conference. This non-legally binding document set forth certain aspirations for countries to follow to sufficiently take action on the global food problem. Ultimately this document outline and provided guidance as to how the international community as one could work towards fighting and solving the growing global issue of malnutrition and hunger.
Adoption of the right to food was included in the Additional Protocol to the American Convention on Human Rights in the area of Economic, Social, and Cultural Rights, this 1978 document was adopted by many countries in the Americas, the purpose of the document is, "to consolidate in this hemisphere, within the framework of democratic institutions, a system of personal liberty and social justice based on respect for the essential rights of man."A later document in the timeline of global inititaves for malnutrition was the 1996 Rome Declaration on World Food Security, organized by the Food and Agriculture Organization. This document reaffirmed the right to have access to safe and nutritious food by everyone, also considering that everyone gets sufficient food, and set the goals for all nations to improve their commitment to food security by halving their amount of undernourished people by 2015. In 2004 the Food and Agriculture Organization adopted the Right to Food Guidelines, which offered states a framework of how to increase the right to food on a national basis.

Special populations
Undernutrition is an important determinant of maternal and child health, accounting for more than a third of child deaths and more than 10 percent of the total global disease burden according to 2008 studies.

Children
Undernutrition adversely affects the cognitive development of children, contributing to poor earning capacity and poverty in adulthood. The development of childhood undernutrition coincides with the introduction of complementary weaning foods which are usually nutrient deficient. The World Health Organization estimates that malnutrition accounts for 54 percent of child mortality worldwide, about 1 million children. There is a strong association between undernutrition and child mortality. Another estimate also by WHO states that childhood underweight is the cause for about 35% of all deaths of children under the age of five years worldwide. Over 90% of the stunted children below five years of age live in sub-Saharan Africa and South Central Asia. Although access to adequate food and improving nutritional intake is an obvious solution to tackling undernutrition in children, the progress in reducing children undernutrition is disappointing.

Women
Researchers from the Centre for World Food Studies in 2003 found that the gap between levels of undernutrition in men and women is generally small, but that the gap varies from region to region and from country to country. These small-scale studies showed that female undernutrition prevalence rates exceeded male undernutrition prevalence rates in South/Southeast Asia and Latin America and were lower in Sub-Saharan Africa. Datasets for Ethiopia and Zimbabwe reported undernutrition rates between 1.5 and 2 times higher in men than in women; however, in India and Pakistan, datasets rates of undernutrition were 1.5–2 times higher in women than in men. Intra-country variation also occurs, with frequent high gaps between regional undernutrition rates. Gender inequality in nutrition in some countries such as India is present in all stages of life.Studies on nutrition concerning gender bias within households look at patterns of food allocation, and one study from 2003 suggested that women often receive a lower share of food requirements than men. Gender discrimination, gender roles, and social norms affecting women can lead to early marriage and childbearing, close birth spacing, and undernutrition, all of which contribute to malnourished mothers.Within the household, there may be differences in levels of malnutrition between men and women, and these differences have been shown to vary significantly from one region to another, with problem areas showing relative deprivation of women. Samples of 1000 women in India in 2008 demonstrated that malnutrition in women is associated with poverty, lack of development and awareness, and illiteracy. The same study showed that gender discrimination in households can prevent a womans access to sufficient food and healthcare. How socialization affects the health of women in Bangladesh, Najma Rivzi explains in an article about a research program on this topic. In some cases, such as in parts of Kenya in 2006, rates of malnutrition in pregnant women were even higher than rates in children.Women in some societies are traditionally given less food than men since men are perceived to have heavier workloads. Household chores and agricultural tasks can in fact be very arduous and require additional energy and nutrients; however, physical activity, which largely determines energy requirements, is difficult to estimate.

Physiology
Women have unique nutritional requirements, and in some cases need more nutrients than men; for example, women need twice as much calcium as men.

Pregnancy and breastfeeding
During pregnancy and breastfeeding, women must ingest enough nutrients for themselves and their child, so they need significantly more protein and calories during these periods, as well as more vitamins and minerals (especially iron, iodine, calcium, folic acid, and vitamins A, C, and K). In 2001 the FAO of the UN reported that iron deficiency affected 43 percent of women in developing countries and increased the risk of death during childbirth. A 2008 review of interventions estimated that universal supplementation with calcium, iron, and folic acid during pregnancy could prevent 105,000 maternal deaths (23.6 percent of all maternal deaths). Malnutrition has been found to affect three quarters of UK women aged 16–49 indicated by them having less folic acid than the WHO recommended levels.Frequent pregnancies with short intervals between them and long periods of breastfeeding add an additional nutritional burden.

Educating children
"Action for healthy kids" has created several methods to teach children about nutrition. They introduce 2 different topics, self-awareness which teaches children about taking care of their own health and social awareness, which is how culinary arts vary from culture to culture. As well as its importance when it comes to nutrition. They include eBooks, tips, cooking clubs. including facts about vegetables and fruits.Team Nutrition has created "MyPlate eBooks" this includes 8 different eBooks to download for free. These eBooks contain drawings to color, audio narration, and a large number of characters to make nutrition lessons entertaining for children.According to the FAO, women are often responsible for preparing food and have the chance to educate their children about beneficial food and health habits, giving mothers another chance to improve the nutrition of their children.

Elderly
Malnutrition and being underweight are more common in the elderly than in adults of other ages. If elderly people are healthy and active, the aging process alone does not usually cause malnutrition. However, changes in body composition, organ functions, adequate energy intake and ability to eat or access food are associated with aging, and may contribute to malnutrition. Sadness or depression can play a role, causing changes in appetite, digestion, energy level, weight, and well-being. A study on the relationship between malnutrition and other conditions in the elderly found that malnutrition in the elderly can result from gastrointestinal and endocrine system disorders, loss of taste and smell, decreased appetite and inadequate dietary intake </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Follicular thyroid cancer and can you explain it in depth? [/INST] Follicular thyroid cancer accounts for 15% of thyroid cancer and occurs more commonly in women over 50 years of age. Thyroglobulin (Tg) can be used as a tumor marker for well-differentiated follicular thyroid cancer. Thyroid follicular cells are the thyroid cells responsible for the production and secretion of thyroid hormones.

Cause
Associated mutations
Approximately one-half of follicular thyroid carcinomas have mutations in the Ras subfamily of oncogenes, most notably HRAS, NRAS, and KRAS. Mutations in MINPP1 have likewise been observed, as well as germline PTEN gene mutations responsible for Cowden syndrome of which follicular thyroid cancer is a feature. Also, a chromosomal translocation specific for follicular thyroid carcinomas is one between paired box gene 8 (PAX-8), a gene important in thyroid development, and the gene encoding peroxisome proliferator-activated receptor γ 1 (PPARγ1), a nuclear hormone receptor contributing to terminal differentiation of cells. The PAX8-PPARγ1 fusion is present in approximately one-third of follicular thyroid carcinomas, specifically those cancers with a t(2;3)(q13;p25) translocation, permitting juxtaposition of portions of both genes. Tumors tend carry either a RAS mutation or a PAX8-PPARγ1 fusion, and only rarely are both genetic abnormalities present in the same case. Thus, follicular thyroid carcinomas seem to arise by two distinct and virtually nonoverlapping molecular pathways.

Hurthle cell variant
Hurthle cell thyroid cancer is often considered a variant of follicular cell carcinoma. Hurthle cell forms are more likely than follicular carcinomas to be bilateral and multifocal and to  metastasize to lymph nodes. Like follicular carcinoma, unilateral hemithyroidectomy is performed for non-invasive disease, and total thyroidectomy for invasive disease.

Diagnosis
It is difficult to correctly diagnose follicular neoplasms (FNs) on fine-needle aspiration cytology (FNAC) because it shares many cytological features with other mimicking lesions.

Classification
It is impossible to distinguish between follicular adenoma and  carcinoma on cytological grounds. If fine needle aspiration cytology (FNAC) suggests follicular neoplasm, thyroid lobectomy should be performed to establish the histopathological diagnosis.  Features sine qua non for the diagnosis of follicular carcinoma are capsular invasion and vascular invasion by tumor cells. Still, focuses of the capsular invasion should be carefully evaluated and discriminated from the capsular rupture due to FNA penetration resulting in WHAFFT (worrisome histologic alterations following FNA of thyroid).

Follicular carcinoma tends to metastasize to lung and bone via the bloodstream.
Papillary thyroid carcinoma commonly metastasizes to cervical lymph nodes.HMGA2 has been proposed as a marker to identify malignant tumors.

Treatment
Treatment is usually surgical, followed by radioiodine.

Initial treatment
If follicular cells are found on cytological testing, it is common to carry out hemithyroidectomy to distinguish between follicular adenoma and follicular carcinoma on histopathological examination, proceeding to completion thyroidectomy and postoperative radioiodine ablation where carcinoma is confirmed.  This way total thyroidectomy is not carried out unnecessarily.
Thyroidectomy is invariably followed by radioiodine treatment at levels from 50 to 200 millicuries following two weeks of a low iodine diet (LID) </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Stab wound and can you explain it in depth? [/INST] A stab wound is a specific form of penetrating trauma to the skin that results from a knife or a similar pointed object. While stab wounds are typically known to be caused by knives, they can also occur from a variety of implements, including broken bottles and ice picks. Most stabbings occur because of intentional violence or through self-infliction. The treatment is dependent on many different variables such as the anatomical location and the severity of the injury. Even though stab wounds are inflicted at a much greater rate than gunshot wounds, they account for less than 10% of all penetrating trauma deaths.

Management
Stab wounds can cause various internal and external injuries. They are generally caused by low-velocity weapons, meaning the injuries inflicted on a person are typically confined to the path it took internally, instead of causing damage to surrounding tissue, which is common of gunshot wounds. The abdomen is the most commonly injured area from a stab wound. Interventions that may be needed depending on severity of the injury include airway, intravenous access, and  control of hemorrhage. The length and size of the knife blade, as well as the trajectory it followed, may be important in planning management as it can be a predictor of what structures were damaged. There are also special considerations to take into effect as given the nature of injuries, there is a higher likelihood that persons with these injuries might be under the influence of illicit substances which can make it harder to obtain a complete medical history. Special precautions should also be taken to prevent further injury from a perpetrator to the victim in a hospital setting. Similarly to treating shock, it is important to keep the systolic pressure above 90mmHg, maintain the persons core body temperature, and for prompt transport to a trauma center in severe cases.To determine if internal bleeding is present a focused assessment with sonography (FAST) or diagnostic peritoneal lavage (DPL) can be used. Other diagnostic tests such as a computed tomography scan or various contrast studies can be used to more definitively classify the injury in both severity and location. Local wound exploration is also another technique that may be utilized to determine how far the object penetrated. Observation can be used in place of surgery as it can substitute an unnecessary surgery, which makes it the preferred treatment of penetrating trauma secondary to a stab wound when hypovolemia or shock is not present. Laboratory diagnostic studies such as a hematocrit, white blood cell count and chemical tests such as liver function tests can also help to determine the efficiency of care.

Surgery
Surgical intervention may be required but it depends on what organ systems are affected by the wound and the extent of the damage. It is important for care providers to thoroughly check the wound site in as much as a laceration of an artery often results in delayed complications sometimes leading to death. In cases where there is no suspicion of bleeding or infection, there is no known benefit of surgery to correct any present injuries. Typically a surgeon will track the path of the weapon to determine the anatomical structures that were damaged and repair any damage they deem necessary. Surgical packing of the wounds is generally not the favored technique to control bleeding as it can be less useful than fixing the directly affected organs. In severe cases when homeostasis cannot be maintained the use of damage control surgery may be utilized.

Epidemiology
Stab wounds are one of the most common forms of penetrating trauma globally, but account for a lower mortality compared to blunt injuries due to their more focused impact on a person. Stab wounds can result from self-infliction, accidental nail gun injuries, and stingray injuries, however, most stab wounds are caused by intentional violence, as the weapons  used to inflict such wounds are readily available compared to guns.  Stabbings are a relatively common cause of homicide in Canada and the United States. Typically death from stab wounds is due to organ failure or blood loss. They are the mechanism of approximately 2% of suicides.In Canada, homicides by stabbing and gunshot occur relatively equally (1,008 to 980 for the years 2005 to 2009). In the United States guns are a more common method of homicide (9,484 versus 1,897 for stabbing or cutting in 2008).Stab wounds occur four times more than gunshot wounds in the United Kingdom, but the mortality rate associated with stabbing has ranged from 0-4% as 85% of injuries sustained from stab wounds only affect subcutaneous tissue. Most assaults resulting in a stab wound occur to and by men and persons of ethnic minorities.

History
Some of the first principles of wound care come from Hippocrates who promoted keeping wounds dry except for irrigation. Guy de Chauliac would promote removal of foreign bodies, rejoining of severed tissues, maintenance of tissue continuity, preservation of organ substance, and prevention of complications. The first successful operation on a person who was stabbed in the heart was performed in 1896 by Ludwig Rehn, in what is now considered the first case of heart surgery. In the late 1800s it was hard to treat stab wounds because of poor transportation of victims to health facilities and the low ability for surgeons to effectively repair organs. However, the use of laparotomy, which has been developed a few years earlier, had provided better patient outcomes than had been seen before. After its inception, the use of exploratory laparotomies was highly encouraged for "all deep stab wounds" in which surgeons were to stop active bleeding, repair damage, and remove "devitalized tissues". Because laparotomies were seen to benefit patients, they were used on most every person with an abdominal stab wound until the 1960s when doctors were encouraged to use them more selectivity in favor of observation </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Haemobilia and can you explain it in depth? [/INST]  </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Thallium poisoning and can you explain it in depth? [/INST] Thallium poisoning is poisoning that is due to thallium and its compounds, which are often highly toxic. Contact with skin is dangerous and adequate ventilation should be provided when melting this metal. Many thallium compounds are highly soluble in water and are readily absorbed through the skin. Exposure to them should not exceed 0.1 mg per m2 of skin in an 8 hour time-weighted average (40- hour working week). Thallium is a suspected human carcinogen.Part of the reason for thalliums high toxicity is that when present in aqueous solution as the univalent thallium(I) ion (Tl+) it exhibits some similarities with essential alkali metal cations, particularly potassium (owing to similar ionic radii). It can thus enter the body via potassium uptake pathways. Other aspects of thalliums chemistry differ strongly from that of the alkali metals, such as its high affinity for sulfur ligands. Thus this substitution disrupts many cellular processes by interfering with the function of proteins that incorporate cysteine, an amino acid containing sulfur. Thalliums toxicity has led to its use (now discontinued in many countries) as a rat and ant poison.Among the distinctive effects of thallium poisoning are peripheral nerve damage (victims may experience a sensation of “walking on hot coals”) and hair loss (which led to its initial use as a depilatory before its toxicity was properly appreciated). However hair-loss generally occurs only with low doses; with high doses the thallium kills before hair loss can occur. Thallium was an effective murder weapon before its effects became understood and an antidote (Prussian blue) discovered. It has been called the "poisoners poison" since it is colorless, odorless and tasteless; its slow-acting, painful and wide-ranging symptoms are often suggestive of a host of other illnesses and conditions.

Cause
Bioconcentration
According to the United States Environmental Protection Agency (EPA), thallium release to the environment was reported in Texas and Ohio. This may indicate bioconcentration in aquatic ecosystems.

Thallium compounds
The odorless and tasteless thallium sulfate was also used as rat poison and ant killer. Since 1975, this use in the United States and many other countries is prohibited due to safety concerns.

Diagnosis
Thallium may be measured in blood or urine as a diagnostic tool in clinical poisoning situations or to aid in the medicolegal investigation of suspicious deaths. Normal background blood and urine concentrations in healthy persons are usually less than 1 μg/litre, but they are often in the 1–10 mg/litre range (1,000–10,000 times higher) in survivors of acute intoxication.  Thallium is present in the blood for a very short time so urine testing is usually most appropriate.  A quick way to assess possible thallium poisoning is to perform a microscopic analysis of a hair and its root. In thallium poisoning this analysis will show a tapered anagen hair with black pigmentation at the base (anagen effluvium). This is pathognomonic for thallium toxicity.

Treatment
There are two main methods of removing both radioactive and stable isotopes of thallium from humans. First known was to use Prussian blue, which is a solid ion exchange material, which absorbs thallium. Up to 20 g per day of Prussian blue is fed by mouth to the person, and it passes through their digestive system and comes out in the stool. Hemodialysis and hemoperfusion are also used to remove thallium from the blood stream. At later stage of the treatment additional potassium is used to mobilize thallium from the tissue.

Notable cases
There are numerous recorded cases of fatal thallium poisoning. Because of its use for murder, thallium has gained the nicknames "The Poisoners Poison" and "Inheritance Powder" (alongside arsenic).

Australias "Thallium Craze"
In Australia, in the early 1950s, there was a notable spate of cases of murder or attempted murder by thallium poisoning. At this time, due to the chronic rat infestation problems in overcrowded inner-city neighbourhoods (notably in Sydney), and thalliums effectiveness as a rat poison, it was still readily available over the counter in New South Wales, where thallium sulphate was marketed as a commercial rat bait, under the brand Thall-rat .

In September 1952 Yvonne Gladys Fletcher, a housewife and mother of two from the inner Sydney suburb of Newtown, was charged and tried for the murders of both her first husband, Desmond Butler (who died in 1948), and her abusive second husband, Bertrand "Bluey" Fletcher, a rat-bait layer, from whom she had obtained the thallium poison that she used to kill him earlier that year. Suspicions were raised after it became obvious to friends and neighbours that Bluey Fletcher was suffering from the same fatal illness that had killed Yvonnes first husband. A police investigation led to the exhumation and testing of Desmond Butlers remains, which showed clear evidence of thallium, and this led to Yvonne being convicted of Butlers murder. She was sentenced to death but the sentence was commuted to life imprisonment after the NSW Government abolished the death penalty; she was eventually released in 1964. At the time of the trial it was reported that this was the first known case in Australia of a person being convicted of murder by administering thallium. The Fletcher case is also notable for the fact that one of the arresting officers was Sydney detective Fred Krahe, who later became notorious for his suspected close involvement with elements of Sydneys organised crime scene and his alleged involvement in the disappearance of social activist Juanita Nielsen.
A month later, in October 1952, Bathurst grandmother Ruby Norton was tried for the murder of her daughters fiancé, Allen Williams, who died of thallium poisoning at Cowra Hospital in July 1952. Despite allegations that Norton hated all the men in her family and that she did not want Williams as a son-in-law, Norton was acquitted.
In 1953 Sydney woman Veronica Monty, 45, was tried for the attempted murder of her son-in-law, noted Balmain and Australian rugby league player Bob Lulham, who was treated for thallium poisoning in 1952. After separating from her husband Monty had moved in with her daughter Judy and Judys husband, Bob Lulham. The sensational trial revealed that Lulham and Monty had an "intimate relationship" while Lulhams wife was at Sunday mass. Monty was found not guilty; Judy Lulham divorced her husband as a result of the revelations about his affair and Monty killed herself with thallium in 1955.
In July 1953, Sydney woman Beryl Hague was tried for "maliciously administering thallium and endangering her husbands life". Hague confessed to buying Thall-rat from a corner shop and putting it in her husbands tea because she wanted to "give him a headache to repay the many headaches he had given me" in violent disputes.
In 1953 Australian Caroline Grills was sentenced to life in prison after three family members and a close family friend died. Authorities found thallium in tea that she had given to two other family members. Grills spent the rest of her life in Sydneys Long Bay Gaol, where fellow inmates dubbed her "Aunt Thally".The Australian TV documentary Recipe for Murder, released in 2011, examined three of the most sensational and widely reported Australian thallium poisonings, the Fletcher, Monty and Grills cases.

Others
Félix-Roland Moumié, a Cameroonian leader, was assassinated with thallium in Geneva on 3 November 1960 by a former agent of the SDECE (French secret service) probably at the request of Cameroonian authorities.
In 1971, thallium was the main poison that Graham Frederick Young used to poison around 70 people in the English village of Bovingdon, Hertfordshire, of whom three died.
From 1976 to late 1979, thallium was used as a chemical warfare agent, most notably by a unit of the British South Africa Police (BSAP) attached to the Selous Scouts during the Rhodesian Bush War.
In 1977, a 19 month-old girl living in Qatar fell ill due to thallium poisoning (from pesticides used by her parents). While doctors were unable to identify the cause, a nurse named Marsha Maitland managed to do it from the description of the symptoms given in The Pale Horse.
In summer 1981 the East German secret service "Stasi" poisoned dissident Wolfgang Welsch, who had previously been expelled to West Germany, during his holiday in Israel. He barely survived.
In 1985, spiritual leader Rajneesh was allegedly poisoned with small doses of poison, by Reagan Administration and Church, as per accounts of his followers. This allegation was never proven. He died after 5 years in 1990.
In 1987, in Kyiv, a woman named Tamara Ivanutina was arrested along with her older sister and parents. They were found guilty of 40 cases of poisoning (13 of them lethal) with Clerici solution obtained from an acquaintance working at a geology institute. Tamara (guilty of nine deaths, including four children) was executed in one of the three documented cases of women receiving the capital punishment in post-Stalin Soviet Union. Her relatives received prison terms, the parents dying in jail.
In 1988, members of the Carr family from Alturas, Polk County, Florida, fell ill from what appeared to be thallium poisoning. Peggy Carr, the mother, died slowly and painfully from the poison. Her son and stepson were critically ill but eventually recovered. The Carrs neighbor, chemist George J. Trepal, was convicted of murdering Mrs. Carr and attempting to murder her family, and sentenced to death. The thallium was slipped into bottles of Coca-Cola at the Carr and Trepal homes.
Thallium was the poison of choice for Saddam Hussein to use on dissidents, which even allowed for them to emigrate before dying.
In 1995, Zhu Ling was the victim of an unsolved attempted thallium poisoning in Beijing, China. In 1994, Zhu Ling was a sophomore studying physical chemistry at Tsinghua University in Beijing. She began to show strange and debilitating symptoms at the end of 1994, when she reported experiencing acute stomach pain and extensive hair loss. Ultimately she was diagnosed on Usenet with poisoning by thallium. To this day, there is still speculation among Chinese expatriates overseas as to the poisoners identity. The only suspect of the police investigation, Sun Wei, is a member of a family with high-level political connections, which may have been used to halt and suppress the results of the investigation. Sun Wei was Zhu Lings classmate and roommate in Tsinghua University from 1992–1997. Tsinghua University also said she was the only student who had access to thallium compounds at the school. The investigations results have never been released to Zhu Lings parents or the general public. However, Tsinghua University declined to issue Sun Weis B.S. certificate and refused to provide her with the documentation needed to get a passport or visa in 1997. In 2018 the victims hair has been examined by the University of Maryland geologist Richard Ash using laser ablation ICP-MS mass spectrometry. He was able to confirm the timeline and pattern of poisoning.
In 1999, Norwegian Terje Wiik was sentenced to 21 years imprisonment for poisoning his girlfriend with thallium.
In June 2004, 25 Russian soldiers earned Honorable Mentions in the Darwin Awards after becoming ill from thallium exposure when they found a can of mysterious white powder in a rubbish dump on their base at Khabarovsk in the Russian Far East. Oblivious to the danger of misusing an unidentified white powder from a military dump site, the conscripts added it to tobacco, and used it as a substitute for talcum powder on their feet.
In 2005, a 17 year-old girl in Izunokuni, Shizuoka, Japan admitted to attempting to murder her mother by lacing her tea with thallium, causing a national scandal.
In February 2007, two Americans, Marina and Yana Kovalevsky, a mother and daughter, visiting Russia were hospitalized for thallium poisoning. Both had emigrated from the Soviet Union to the United States in 1991 and had made several trips to Russia since then.
In January 2008, 10 members of two families associated with an Iraqi soccer club, including several children, were poisoned by cake contaminated with thallium. Four died, including two children.
In 2011, a chemist at Bristol-Myers Squibb in New Jersey, Li Tianle, was charged with the murder of her husband. According to an investigation by the Middlesex County Prosecutors Office, Li Tianle was able to obtain a chemical containing thallium and fed it to her husband. Li was a chemistry student at Beijing University at the time of the highly publicized thallium poisoning of Zhu Ling in 1995 at neighboring Tsinghua University.
In 2012 a chemistry postgraduate student at the University of Southampton, UK, was found to be suffering from the effects of thallium and arsenic poisoning after presenting with neurological symptoms. The student underwent an intensive course of treatment and, although he has shown improvement, faces an uncertain long-term prognosis for the recovery of full locomotion. Urine screening revealed elevated thallium levels in a small number of other members of the chemistry department, though none were at toxic levels. The source of the poisoning remains unknown, and although police investigations were fruitless, foul play is strongly suspected.
In 2018, authorities charged Yukai Yang, a student at Lehigh University, with the attempted murder of his roommate, Juwan Royal. Yang allegedly poisoned Royal with thallium and possibly other chemicals. Royal experienced vomiting, pain and numbness in his lower extremities, and a long-lasting burning sensation on his tongue.
In 2022, an English family court found an unnamed doctor guilty of using thallium in a pot of coffee to kill his partners father and injuring the partner and her mother in 2012.  The case is unusual because it was in a family court, arising out of child-custody matters, rather than a criminal case.

In fiction
Ngaio Marsh used thallium acetate in her 1947 detective novel, Final Curtain. It was being used legitimately for scalp problems in a group of school children just after World War II, housed in a private estate. A relative living there used it in place of the heart medicine intended for the owner.
Agatha Christie, who worked as an apothecarys assistant, used thallium in 1961 as the agent of murder in her detective fiction novel The Pale Horse – the first clue to the murder method coming from the hair loss of the victims. This novel is notable as being credited with having saved at least two lives after readers recognised the symptoms of thallium poisoning that Christie described. The Pale Horse was found among possessions of convicted thallium poisoner George Trepals wife, the orthopedic surgeon Dr. Diana Carr (see above), who was herself considered a suspect in the Peggy Carr (no relation) murder for a time.
In Nigel Williams 1990 novel The Wimbledon Poisoner, Henry Far uses thallium to baste a roast chicken in a failed attempt to murder his wife.
Thallium figures prominently in the 1995 film The Young Poisoners Handbook, a dark comedy loosely based on the life of Graham Frederick Young.
In Big Nothing, Josie is the Wyoming Widow; a murderer who befriended men and killed them with whiskey laced with highly concentrated thallium.
In the 2007 episode "Whatever It Takes" of House, a character uses thallium to poison a patient to mimic the effects of polio, then appear to cure it with ultra-high doses of vitamin C.
In the NCIS episode "Dead Man Walking" (2007), thallium-laced cigars are used to murder a Naval officer.
"Page Turner", a 2008 episode of CSI: NY, has radioactive thallium poisoning as its central theme.
In the 2010 film Edge of Darkness, thallium is used to poison both the main character and his daughter.
In the 2015 James Bond film Spectre, the organisation of the same name used thallium to poison Mr. White by lacing his mobile phone with it.
In Season 3 of Royal Pains, the mysterious German billionaire Boris Kuester von Jurgens-Ratenicz was poisoned by thallium added to his pools water.
In Drop Dead Diva episode "Ashes to Ashes", thallium was used to murder a clients husband, affecting the client when she ate the cremation remains.
In the 2016 TVB drama Two Steps From Heaven, thallium was used to poison Bosco Wongs character.
In S6:E10 of the Father Brown Series, Hercule Flambeaus wife poisons Father Brown with thallium in order to induce Flambeau to exchange a religious relic for her giving Brown the antidote.  Guessing the substance his wife used, Flambeau gives Brown clues as to the antidote, Prussian Blue.
In S6:E9 of Elementary, entitled "Nobody Lives Forever" (2018), a biology professor studying how to prolong life spans is poisoned with thallium. As he dies, he falls onto a shelf containing his lab rats, which escape and eventually eat part of his body. Some dead rats are found inside him, suggesting to the detectives that the cause of death was poisoning.

References
External links

"Thallium, elemental". National Institutes of Health. NLM hazardous substances databank. U.S. Department of Health and Human Services.
Curley, Robert </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Familial progressive hyperpigmentation and can you explain it in depth? [/INST]  </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Carditis and can you explain it in depth? [/INST]  </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Mast cell activation syndrome and can you explain it in depth? [/INST] Mast cell activation syndrome (MCAS) is a type of mast cell activation disorder (MCAD), and is an immunological condition in which mast cells inappropriately and excessively release chemical mediators, resulting in a range of chronic symptoms, sometimes including anaphylaxis or near-anaphylaxis attacks. Primary symptoms include cardiovascular, dermatological, gastrointestinal, neurological and respiratory problems.Multiple diagnostic schemes for MCAS have been proposed, and the condition is increasingly over-diagnosed or misdiagnosed.

Signs and symptoms
MCAS is a condition that affects multiple systems, generally in an inflammatory manner. Symptoms typically wax and wane over time, varying in severity and duration. Many signs and symptoms are the same as those for mastocytosis, because both conditions result in too many mediators released by mast cells. It has many overlapping characteristics with recurrent idiopathic anaphylaxis, although there are distinguishing symptoms, specifically hives and angioedema.Common symptoms include:
Dermatological
flushing
hives
easy bruising
either a reddish or a pale complexion
itchiness
burning feeling
dermatographism
Cardiovascular
lightheadedness, dizziness, presyncope, syncope, arrhythmia, tachycardia
Gastrointestinal
diarrhea and/or constipation, cramping, intestinal discomfort
nausea, vomiting, acid reflux
swallowing difficulty, throat tightness
Respiratory
congestion, coughing, wheezing
Anaphylaxis If too many mediators are released into a patients system, they may also experience anaphylaxis, which primarily includes: difficulty breathing, itchy hives, flushing or pale skin, feeling of warmth, weak and rapid pulse, nausea, vomiting, diarrhea, dizziness and fainting.

Causes
There are no known causes, but the condition appears to be inherited in some patients. Symptoms of MCAS are caused by excessive chemical mediators inappropriately released by mast cells </s>