Saturday, February 21, 2015

Final MD Past Questions in Pediatrics, IOM



Either I was too lazy to type or wanted it like this, here are the past papers of MD pediatrics collection. Hope this will be helpful.







Thursday, February 5, 2015

WHERE , WHEN, HOW AND NOW WHAT ? CONGENITALLY MISSING TEETH


The perfect smile on a parent’s face rotates to a frown when they are informed that their child may have less number of teeth than normal. The total number of teeth in the primary dentition is 20 and that in the adult dentition is 32. The parents may not be more worried about losing a tooth to dental decay than they are to know that the teeth are missing congenitally. So when we break the news to parents about these missing teeth, they question …Where? When? How? And now what?

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Dental Terminologies:
  • Hypodontia: 1 to 6 teeth missing
  • Oligodontia:more than six teeth missing
  • Anodontia: complete absence of teeth

How common is it?
Congenitally missing teeth are one of the most common dental findings and is even more common than having extra tooth. It is reported to vary from 2.6 to 11.3% (excluding third molars) in permanent dentition. It is more commonly seen in permanent dentition and only about 0.5 to 0.9% baby tooth may be missing.

CAUSES OF MISSING TEETH:
GENETIC: The cause may be genetic and the condition may run in the family. Studies have shown that in many cases, multiple genetic and environmental factors act together.
SYNDROMIC: in certain cases it may be found clubbed other medical conditions in the form of a syndrome. E.g. Down’s syndrome, Ectodermal dysplasia
The most common permanent teeth to be congenitally missing are:
  • Wisdom Teeth
  • Second Premolars
  • Upper Lateral Incisors
  • Lower Central Incisors

Management:
In the developmental phase of child (up to the age of 15 to 16 years) the missing tooth space is maintained by giving removable or fixed partial space maintainers are given and no permanent treatment is done
Permanent treatment is as follows:
Replacement of the missing teeth can be done by removal dentures, fixed partial dentures (bridge) or implants
  1. Removable Partial Denture is an appliance that can be put in and taken out of the mouth.  It consists of an acrylic plate that holds the missing teeth.
  2. Bridge: it uses two or three adjacent teeth for support and replaces the missing teeth. The missing as well as supporting teeth are given crowns which are interconnected like a bridge. 
  3. Implant: An implant replaces the missing tooth with a metal root like structure that integrates with the jaw bone and a crown is put on top for a natural tooth like appearance.


Conclusion
Congenitally missing teeth is not as rare as you may have guessed.  The causes are varied, but there are multiple treatment options available. So if you or your near ones are facing such a problem, please visit a dentist as soon as possible.

You can contact with your queries at parajeeta9@yahoo.com


AUTHOR:
http://1.bp.blogspot.com/-XYAtQdWARsM/VF7bGm1YUUI/AAAAAAAAAvM/1uTahIGt6KE/s1600/Dentist%2BNepal.jpg
Dr. Parajeeta Dikshit is an Assistant Professor, Dept of Pedodontics and Preventive Dentistry (Pediatric Dentistry) at Kantipur Dental College teaching hospital and research center Basundhara , Kathmandu and Consultant Pediatric Dentist at Smile Square Dental Care Center, Maharajgunj, Kathmandu.

Sunday, January 11, 2015

Lung Surfactant and Factors affecting its maturation


Origin- Type II alveolar cells and Lamellar bodies

Recycling- 90% is reprocessed, average time for turnover is around 10 hours.
CPAP can prevent excessive loss of surfactant drainage into airways by decreasing depth and length of respiration.

Composition-
Phophatidylcholine ( 70-80%) and phosphatidylglycerol (5-10%)
Phosphatidylinositol, Phosphatidylserine,Phosphatidylethalomine - 10%
Other lipids- 10%, 2% surfactant lipids
Surfactant Proteins- SP-A, SP-B, SP-C, SP-D (5-10%)



Function-
Decreases surface tension of alveoli in Laplace equation ie P= 2 gamma/ r


Factors Affecting Surfactant maturation-

1. Glucocorticoids- Intrinsic cortisol accelerates surfactant maturation. Dexamethasone administered increases expression of beta-adrenergic receptors with resultant increase in surfactant production.

2.Beta- adrenergic Drugs- Terbutalline, Formeterol increase cAMP and increase production and secretion of Surfactant

3. Thyroid Hormones- T4 has enhancing property on lung maturation and surfactant secretion however, it does not cross placenta.

4.Prolactin is under study. However low prolactin has been seen in infants with RDS.

5.Epidermal growth factor- Has shown to increase SP-A and L:S ratio in non-human models.

6. Fibroblast pneumocyte factor- under study

7. Insulin- delays the maturation of alveolar type II cells and decrease production of saturated Phosphatidylcholine. It inhibits the expression of SP-A gene.

8, Testosterone- delays the lung maturation through its action on lung fibroblast.


Errors of Surfactant Metabolism-
Polymorphism of SP-A expression- predisposition to sever RSV infection and increase risk for BPD.
SP-B polymorhism- RDS 
SP-C deficiency- Interstitial Lung disease
SP-D- Alveolar accumulation of lipids and proteins.


Monday, January 5, 2015

The Newborn Book - Janelle Aby : Review


I happened to be one of the lucky people to receive a Complimentary copy of this book " The Newborn Book" by Dr Janelle L. Aby . Well I am forgetting this fact for a while and I am writing a Sincere review of this book.

" The Newborn Book" has focused on 'the Significance of Physical Findings in the Neonate' which by far is the first book of its kind.
We are well known to Books like Avery, Roberton, Also Meherban Singh and Cloherty are equally popular in our institutes. All excellent books that have elaborated on the Disease and Management protocols in newborn.




This book particularly is a Basic for every pediatrician, neonatologist and wanna be people. The book is an Atlas of all physical findings in newborn with collections of best photos of such findings. It has an elaborate column on all sorts of findings we may encounter in our nurseries and Outpatient doors , seen commonly even in well babies. Most often we miss findings in newborn and often we are perplexed by findings we have never seen before in any books. I think this book is an answer to this gap that been seen. It can be even used as reference in such cases.Along with the photos, there are useful description and management plan as well.

The content includes
- Prenatal USG findings- commonly encountered conditions
-General Characteristics
- Findings from Head to Toe- Body part wise including Rare findings ( many of which we may have encounter and ignored)
-Body fluids and substances.

What is Good about the book?
1. Simple and concise topics - 250 neonatal findings
2. Excellent photo galleries of findings ( Kind of like Kanski )- 600+ full color photographs
3. Well referenced writings
4. Reviewed by great people
5. The Quality of the book is top-class including design and paper quality

Most importantly the Author is a well-experienced pediatrician indulged in academics.


I believe that This book is one Every Library in Medical college will eventually have and most Pediatrician and Neonatologist will have in near future, as I see this will be one of the best references in Neonatology. We must be able to know and identify findings before proceeding to management part.

As this is the first edition, there might be still rooms for improvement. More topics can be included and book can be made broader and longer , so as to make it more attractive and atlas like.

You can Visit
http://thenewbornbook.org/ for more details and in case you want to keep a copy of it.

Hope you benefited from my review. I am still going through topics in the book, as I am keen in Neonatology and actually I am already into my interest in my Hospital.
Any Comments are welcomed.

Friday, January 2, 2015

Approach to a Child with Short stature


Short Stature-

Height Below 3rd Centile or more than -2 SD height for Age and Gender for the standard population.
When height is > -3 SD its most likely pathological.




Assessment of Short stature-

1. Accurate height measurement using Stadiometer for <2yrs and on Frankfurt plane for older children.

2.Assess height velocity-  cm/year

3. Mid-parental height-
Estimated Final Height = 
(Ht of father in cm  + height of mother in cm + 13 cm)/2 in Males
(Ht of father in cm  + height of mother in cm - 13 cm)/2 in Females 
 Also see Assessment of height.

4. Assessment of Body Proportion- Upper segment Lower segment ratio- Normal, low or high

5. Sexual Maturity Rating- Normal, Delayed or Advanced


Etiological Assessment and Classification-

Click on the chart to enlarge-



Legend- CDGP: Constitutional delay in Growth and puberty

Can be classified on the basis of Upper:Lower segment ratio, then Physiological and pathological causes.

Keeping in mind the causes, 
history should be sought for-
- history of Low birth weight, IUGR
- family history of short stature ( Achndroplasia, Familial short stature), delayed puberty and menstruation ( CDGP) , bowing legs and skeletal deformities ( Skeletal dysplasias)

Symptoms - systemic
- Renal- polyuria, Hypertension, Pallor, hematuria
-CNS- Cerebral palsy, 
- history of jaundice, white stool, bulky stool
- Recurrent UTI

Neonatal history- hypoglycemia, jaundice, micropenis
Any chronic illness, drug or hormone intake
Social environment


Examination-
Body Proportions, Skeletal ratios- Rhizomelia, phocomelia etc
Skeletal abnormalities
Dysmorphism
Kypho-scoliosis
Pallor, Hypertension, Jaundice, abdominal distension
Frontal bossing, depressed nasal bridge, Webbed neck
Goitre, corase hair, 
Central obesity, striae


Evaluation-

1. Assess Bone Age and tally with Chronological age-

Bone age is asses by- Tanner's and Whitehouse method or Gruelich-Pyle atlas

Delayed Bone age compared to Chronological age-
All organic cases 
Bone age proportionate to height age
  • CDGP
  • Malnutrition and Systemic Illness- 

Bone age is less than height age-

  • Growth Hormone Deficiency
  • Hypothyroidism
  • Delayed Pubertry  

Bone age is Normal for Chronological Age-
Familial Short stature


Advanced Bone Age -
Cushing Syndrome
Precocious Puberty


Investigations-

If Height is  not below 2 SD, no evaluation- weight and watch 3-6 monthly

If Height < -2 SD, look for SD score-
If > 1 SDS- Physiological varaint
If <-1 SDS- look for Facies, proportions- if abnormal - Genetic, skeletal dysplasias

If Normal Proceed with-

Level I-
Complete blood count, ESR
Bone Age
Renal function test ( CKD)
Urine specific gravity, pH ( RTA, CKD)
Stool RME, Culture, occult blood, pH -( GI inflammations, celiac, malabsorptions)
Liver function test ( CLD, Hepatitis, Obstructive jaundice)
ABG- ( RTA, Barter and Gittelman syndrome, CKD, Any metabolic acidosis)
Blood Sugar- (GH deficiency, Diabetes type I, Addisons disease, Metabolic disorders)

Level II-
Thyroid function Tests
Karyotyping

Level III-

Celiac - TTG for > 2yrs child, Antigliadin Ab for < 2yrs
GH stimulation assay
IGF1 and IGF-BP3 assessment
MRI brain


Managment -

For CDGP and Familial- Counselling

GH therapy for GH deficiency, failure to catch-up Low birth weight children, 
GH is currently approved in the United States for treating children with growth failure as a result of Turner syndrome, end-stage renal failure before kidney transplantation, Prader-Willi syndrome, intrauterine growth retardation, and idiopathic short stature

As per pathology for other causes.

References-
Nelson Textbook of Pediatrics
OP Ghai Essentials of Pediatrics
Review articles