N. K. Arora

Portal hypertension in north Indian children

Etiological factors associated with portal hypertension in children influence the decision about therapy and the prognosis. This cross-sectional observational study was performed at a tertiary care centre in northern India from January, 1990 to December, 1994. Children below the age of 14 years with suspected portal hypertension were prospectively assembled into a cohort to determine the etiology and clinical profile of portal hypertension. Of the 115 patients with portal hypertension, 76.5% had extrahepatic portal hypertension (EHPH). Remaining 23.5% of the cases had intrahepatic and post-hepatic causes of portal hypertension. Children with EHPH had a significantly earlier onset of symptoms as compared to those with intrahepatic portal hypertension (p = 0.002) and bled significantly more frequently (p = 0.00). Forty per cent of patients with chronic liver disease (CLD) never had jaundice. History suggestive of potential etiological factors could be elicited in only 7% of EHPH patients. The commonest site of block in splenoportal axis was at the formation of the portal vein. An inverse relation of bleeding rates with duration of illness was seen in EHPH. Of the 10 CLD patients in whom liver biopsy could be done, cirrhosis was present in 6 patients.Understanding the natural history of EHPH and portal hypertension due to other etiologies may have significant implications in choosing the appropriate intervention and predicting the outcome.

Upper gastrointestinal bleeding: Etiology and management

Upper gastrointestinal bleeding is a potentially fatal condition at times due to loss of large volumes of blood. Common sources of upper gastrointestinal bleeding in children include mucosal lesions and variceal hemorrhage (most commonly extra hepatic portal venous obstruction) and, in intensive care settings infections and drugs are other etiological factors associated with bleeding. Massive upper Gl bleeding is life threatening and requires immediate resuscitation measures in the form of protection of the airways, oxygen administration, immediate volume replacement with ringer lactate or normal saline, transfusion of whole blood or packed cells and also monitoring the adequacy of volume replacement by central venous lines and urine output. Upper Gl endoscopy is an effective initial diagnostic modality to localize the site and cause of bleeding in almost 85–90% of patients. Antacids supplemented by H2-receptor antagonists, proton pump inhibitors and sucralfate are the mainstay in the treatment of bleeding from mucosal lesion. For variceal bleeds, emergency endoscopy is the treatment of choice after initial haemodynamic stabilization of patient. If facilities for endoscopic sclerotherapy (EST) are not available, pharmacotherapy which decreases the portal pressure is almost equally effective and should be resorted to. Shunt surgery is reserved for patients who do not respond to the above therapy. β blockers combined with sclerotherapy have been shown to be the most effective therapy in significantly reducing the risk of recurrent rebleeding from varices as well as the death rates, as compared to any other modality of treatment. Based on studies among adult patients, presence of shock, co-morbidities, underlying diagnosis, presence of stigmata of recent hemorrhage on endoscopy and rebleeding are independent risk factors for mortality due to upper Gl bleeding. Rebleeding is more likely to occur if the patient has hematemesis, liver disease, coagulopathy, hypotension and or anemia. There is a great need for conducting therapeutic trials as well as identifying predictors of outcome of upper Gl bleeding in children to develop evidence based management protocols.

Quantitative vs qualitative research methods.

Quantitative methods have been widely used because of the fact that things that can be measured or counted gain scientific credibility over the unmeasurable. But the extent of biological abnormality, severity, consequences and the impact of illness cannot be satisfactorily captured and answered by the quantitative research alone. In such situations qualitative methods take a holistic perspective preserving the complexities of human behavior by addressing the “why” and “how” questions. In this paper an attempt has been made to highlight the strengths and weaknesses of both the methods and also that a balanced mix of both qualitative as well as quantitative methods yield the most valid and reliable results.

Macronutrient and energy content of breast milk of mothers delivering prematurely

The protein, lactose, fat and energy contents of the fore-milk of mother with term (n=23) and preterm (n=29) infants were estimated on postpartum days 3, 7, 14 and 21. During the first 4 weeks of lactation, the mean (±SD) energy (Kcal/dl), protein (g/dl), fat (g/dl) and lactose (g/dl) levels of the preterm milk were: 56.39 (±7.99), 2.17 (±0.66), 2.30 (±0.48) and 5.78 (±0.99), respectively. The same for term milk were: 59.39 (±8.30), 1.99 (±0.70), 2.48 (±0.53) and 6.24 (±1.08), respectively. The differences in composition between the term and preterm milk were not significant. The composition of breast milk showed changes over the first 3 weeks of lactation. With increasing post-partum days, there was a decline in protein content while fat, lactose and energy contents increased. These trends were more pronounced for preterm milk than term milk. The macronutrient composition and energy estimates of preterm breast milk of Indian mothers in this study may be useful for calculation of nutritional intake by premature neonates fed on expressed breast milk.

Nasopharyngeal carriage ofHaemophilus influenzae

Objective: Nasopharyngeal colonization ofHaemophilus influenzae (H. influenzae) in young children may be important in developing countries.Method: In this study, we screened school going children for carriage ofH. influenzae. A total of 44H. influenzae isolates out of a collection of 162 were characterized for biotypes, capsular serotypes and antibiotic resistance.Results:A significant proportion ofH. influenzae (25/44) isolates were serotype b. High antibiotic resistance was observed against commonly administered antibiotics like ampicillin (79%), chloramphenicol (20%), trimethoprim sulfamethoxazole (84%) and erythromycin (95%). Comparison of antibiotic resistance profile of nasopharyngeal isolates was observed to be correlated with those ofH. influenzae from disease.Conclusion: Multidrug resistant nasopharyngealH. influenzae in young healthy children may act as reservoir. Monitoring of antibiotic resistance among nasopharyngealH. influenzae as a surrogate for invasiveH. influenzae seems an attractive option.

Morbidity and mortality in term infants with intrauterine growth retardation

100 term intrauterine growth-retarded and an identical number of normal grown term infants were followed up during the neonatal period to study their morbidity and mortality pattern in India. More than 1/3 of all growth-retarded infants (37%) had clinical evidence of fetal distress and nearly 1/4 suffered from birth asphyxia (22%). Hypoglycemia was found to be the commonest (12%) handicap in these children. Congenital anomalies occurred in 8% of infants with IUGR. 3 infants with IUGR died and the causes of death were meconium aspiration multiple congenital malformations and septicemia. Meconium aspiration (4%) hypothermia (4%) and septicemia (3%) were limited to infants with IUGR. The mortality was limited to infants who weighed less than -2SD below the expected mean for their gestational age. In light of our observations and limited resources in developing countries it is recommended that specialized nursery care should be provided to only severely growth-retarded infants (i.e. below -2SD). (authors)

Randomized controlled trial and economic evaluation

Conducting economic evaluation alongside clinical trials is an efficient way of getting valid and reliable information with minimum assumptions made during data collection. However, design of a randomised control trial (RCT) takes away several of the real world situations, the variations in resource utilisation, their cost due to close supervision and monitoring of the study subjects. Suitable sensitivity analysis has to be done to make the economic data obtained more pragmatic and hence utilised by the policy makers.

Microbial role in periodontitis: Have we reached the top? Some unsung bacteria other than red complex.

The microbial etiology of periodontal disease has been the focus of researchers for a long time. The search for the pathogens of periodontal diseases has been underway for more than 100 years, and continues up today. Despite the increasing knowledge about oral microbiota, we are not able to implicate any one particular organism that can be considered as a candidate pathogen. In fact the term “candidate pathogen” has lost its steam with a myriad of microorganisms being incriminated from time to time. Most studies of the bacterial etiology of periodontitis have used either culture-based or targeted deoxyribonucleic acid approaches and so it is likely that pathogens remain undiscovered. The advent of 16S cloning and sequencing has facilitated identification of several uncultivable bacteria in the oral cavity. The concept that not one single organism, but several organisms contained in the biofilm orchestrating in a medley of the show appears to be more plausible. The present review highlights some lesser known bacteria associated with periodontal destruction.

Laser excision of peripheral ossifying fibroma: Report of two cases.

Peripheral ossifying fibroma (POF) is a non-neoplastic enlargement seen more often in females, in the interdental papilla and the anterior part of the maxilla, accounts for about 9% of all gingival growths. Of unknown etiology, unpredictable clinical course and pronicity for recurrence, POF is a clinicians cause for concern. Surgical excision is the treatment of choice, but with a reported recurrence rate of 7-45%, the management is often frustrating. With increasing acceptance of lasers in the repertoire of clinicians armory, laser excision of such lesions has become a possible, feasible, and patient-preferred approach. The purpose of this article is to report successful management and 1 year follow-up of two cases of POF using neodymium-doped yttrium aluminum garnet (Nd: YAG) laser. The absence of operative bleeding, relative ease of the procedure and patient acceptance lends the laser excision as an alternate therapeutic modality for excision of gingival enlargements of suspicious and vexatious nature.

Is anti-platelet therapy interruption a real clinical issue? Its implications in dentistry and particularly in periodontics.

The use of anti-platelet therapy has reduced the mortality and morbidity of cardiovascular disease remarkably. A considerable number of patients presenting before a dentist or periodontist give a history of anti-platelet therapy. A clinical dilemma whether to discontinue the anti-platelet therapy or continue the same always confronts the practitioner. Diverse opinions exist regarding the management of such patients. While one group of researchers advise continuation of anti-platelet therapy rather than invite remote, but possible, thromboembolic events, another group encourages discontinuation for variable periods. This study aims at reviewing the current rationale of anti-platelet therapy and the various options available to a clinician, with regard to the management of a patient under anti-platelet therapy. Current recommendations and consensus favour no discontinuation of anti-platelet therapy. This recommendation, however, comes with a rider to use caution and consider other mitigating factors as well. With a large number of patients giving a history of anti-platelet therapy, the topic is of interest and helps a clinician to arrive at a decision.