By now you may already know that the kidneys filter your blood. Microscopically speaking, it is structures known as the glomeruli (singular ‘glomerulus’) inside of the kidney that perform the actual filtration. If they, like the car and fridge filter, are damaged, then they will leak stuff into your urine that normally shouldn’t be there.

A glomerular disorder that causes hypoalbuminemia, proteinuria, and edema is known as nephrotic syndrome. All sorts of glomerulopathies (diseases of the glomerulus) can result in nephrotic syndrome, including: 

• Minimal change disease 
• Focal segmental glomerulosclerosis 
• Membranous nephropathy 
• Diabetic nephropathy 

CAUSES OF NS

Minimal change disease:

• PRIMARY CAUSE: IDIOPATHIC (10–15% of idiopathic NS in adults, but 70–90% of NS in children.)
• SECONDARY CAUSE: HIV
• CAUSED BY DRUGS: NSAIDS, Rifampicin interferon
• NEOOPLASMIC: Hodgkin’s lymphoma
• mc in children

Membranous nephropathy 

• PRIMARY CAUSE: IDIOPATHIC (30% of idiopathic adult NS.)
• SECONDARY CAUSE: Chronic Hep B/C, Syphillis, Leprosy, Hydatid disease
• CAUSED BY DRUGS: NSAIDS, Gold, Penicillamine, Probenecid, Captopril
• NEOOPLASMIC: Paraneoplastic syndrome (IgG) and Ca of breast, lung, ovary and colon.
• mc in elderly and malignant lesions
• maximum risk of renal vein thrombosis

Focal segmental glomerulosclerosis 

• PRIMARY CAUSE: IDIOPATHIC (30% of idiopathic adult NS.)
• SECONDARY CAUSE: Chronic Hep B, Parvo B-19
• CAUSED BY DRUGS: NSAIDS, Heroine intake, Lithium and Panidronate
• NEOOPLASMIC: Non- Hodgkin’s lymphoma
• mc in adults
• mc lesion in HIV

I don’t want you to really get bogged down in remembering the causes of nephrotic syndrome so much as understanding what actually happens. Any of those diseases damage the glomerulus. The glomerulus is the filter that is supposed to keep large things, such as proteins, inside of the blood while filtering out smaller toxins that get excreted in the urine. If the pores of the glomerulus, the little holes that allow for things to pass through the glomerulus and into the urine, are damaged, they get bigger. Bigger pores in any filter means that things that should’ve been kept out are now leaking into the urine and out of the blood. 

You can reproduce this point at home. Take out some dirty old rag you no longer need. If you look really closely, you will see that there are small holes in the rag. They’re truly tiny. This rag will represent our glomerulus, the filter. Turn on the faucet in a sink and place a couple of golf balls or something similar into the rag. Now place all of this under the running faucet. You’ll note that the golf balls aren’t filtered through, but the water and all the microscopic parts of it easily pass through to the other side. 

Now go ahead and cut some big holes into the rag, mimicking the damage glomerulopathies cause. Repeat what you did before. This time around, not only will the water leak through but the golf balls will pass through as well. 

In the case of nephrotic syndrome, a protein called albumin is like a golf ball that leaks out of the blood and into urine when it normally shouldn’t. This leakage results in decreased levels of albumin in the blood, termed hypoalbuminemia and increased levels of protein in the urine, known as proteinuria.

SERUM ALBUMIN= Normal Value is 3.5-5.5 but in NS the value decreases to 2.5 g/dl
PROTENURIA
Old= more than 3.5 g/dl
Children= More than 2g/dl
Adult= More than 3g/dl
Proteinuria during nephrotic syndrome is in the range of three grams per day or more. This is in contrast to other causes of proteinuria, such as a kidney infection, which results in less than that (up to two grams per day, normally). 

You should note that the protein albumin, now leaking out of blood and into the urine, is important in keeping fluid within the blood vessels and out of the body tissues. Albumin is like a sponge that sucks up water into the vasculature. Since there’s less albumin in the blood during nephrotic syndrome, there are fewer sponges in the blood vessels. This means water leaks out of the blood vessels and into the tissues. This is what is known as edema. Edema causes a person to literally swell up with fluid. Keeping this in mind, lets understand:
Initiating Mechanism of Edema:
Decrease in oncotic pressure due to albumin loss —> Fluid shift from intravascular to extravascular—> causing effective decrease in intravascular volume.
Hence, increase in renin and aldosterone leading to increase in water and sodium retention.

• Believe that can you write the paper very well. Believing in yourself is the most important aspect of the preparation.
• Never feel low about yourself and enjoy the preparation with peace of mind.
• Make a list of last year questions and add stars when the question is repeated.
• Roughly, there are at least 30 questions of 9marker and 150 questions of 4 marker for every subject. Read them priority wise or you can read chapter wise 🙂
• Keep 10 days for each subject
• Make the list of topics you need to read for the next day the night before This will motivate you to wake up early and start with direction
• If your mind is wandering, write them down in paper.
• Keep 30 mins alarm on repeat to check on yourself- whether you are reading or using phone.
• Keep one hour for social media.
• Have comfortable environment
• Don’t trust your friends hahah like me.
• When we are genuinely curious we learn better, and especially have better recall. Motivation for learning is important: ask If you are studying for just a grade, or studying because you are curious to learn – this impacts effectiveness.
• You need to work on the hard questions in order to improve. Remember: reading is not studying.
• Mix, or interleave, subjects/topics as you study them. You’ll learn better by mixing things up.
• Be open about your barriers to learning. Is it procrastination? Perfectionism? It can be uncomfortable to face these truths–but the sooner you overcome procrastination the better. And the right time to start studying is now
• Problem-Based Learning: This is when students learn about a topic through open-ended problems and challenges.
• Question Everything: Ask why we know certain things. Ask why things have certain names. When you understand the origin of ideas it helps with recall and learning. Same for understanding word roots.

HOW TO ENJOY THE PREPARATION

• Use Colourful Pens, sticky notes to make it aesthetic and not monotonous
• Use Illustrations, Flowcharts and small Diagrams for every statement in your notes
• Message your Seniors to clear your doubts/concepts. They will link you with references etc
• Have proper diet and sleep- cause it enhances overall productivity
• Divide your day into multiple sessions. Eg: 2 hours session and a 30 mins break.
• If you aren’t able to understand/retain a topic, pretend like your teaching someone.
• Change the room- Study room to dinning room to Parents room
• Reward yourself at the end of the day by talking to your parents or sibling or cousin or friend or boyfriend or girlfriend or closed ones. Watch a funny videos or have a chocolate. This better than rewarding yourself with movies and series.
• Make the list of topics you need to read for the next day the night before. This will motivate you to wake up early and start with direction
• Listen to OM while reading 🙂 LINK:

Graves’ disease is the most common cause of hyperthyroidism, or overactive thyroid. In Graves’, the body’s hyperactive immune system produces an antibody that attaches to the TSH receptors on the thyroid gland. Because TSH isn’t actually triggering the release of T3 and T4, the negative feedback system the body has in place doesn’t work and the thyroid continually makes and releases thyroid hormones. Since the antibodies consistently trigger the thyroid cells to produce more T3 and T4, the body responds by increasing the thyroid’s size, causing a classic thyroid symptom called goiter. 

The other primary external symptom of Graves’ is called exophthalmos, or protrusion of the eyes. Exophthalmos has two causes. The first is due to a prolonged ‘fight or flight’ response – the widening of the eyes by a retraction of the upper lids. The second is due to that overactive immune system: the fat and muscles around the eyes become swollen due to an increase in the number of lymphocytes present and other symptoms of inflammation, pushing the eyes forward. 

Internally, excess thyroid hormones are also stressing the sympathetic nervous system, constantly preparing us for a threat that’s not really there. Resting metabolic rate increases, causing weight loss. Resting heart rate jumps irregularly (arrhythmia) or increases to over 100 beats per minute (tachycardia). Heat intolerance and heavy perspiration are also symptoms. 

Diagnosis of Graves’ through blood tests relies largely on high-circulating levels of T3 and T4 and low TSH levels, as well as antibodies for TSH receptors. Occasionally, an iodine uptake test is used for confirmation. In this test, the patient consumes a low dose of radioactive iodine. Since thyroid cells actively take up iodine, the degree and location of overactive cells present in radiography as darkened areas of the thyroid. 

Pharmaceutical treatment for Graves’ consists of symptom relief through beta blockers, which dull sympathetic nervous system activity, and antithyroid medications that prevent the thyroid from making hormones, such as methimazole. In more severe cases, surgical removal of or destruction of the hyperactive cells through radioactive iodine is a treatment option.

Teething is a term limited by common usage to eruption
of primary dentition. Since the time of Hippocrates (460-
377 BC) teething is blamed for ailments such as fever, convulsions, bronchitis, otitis media and diarrhea, for
causing 12% of the deaths in children under four years.
Complete opposite views are also available. It is seen
that these local and systemic factors are associated with
the disease somewhere else also and just as a coinci-
dence appear with teething.

Eruption of primary dentition usually begins in the 4-6th month of a child’s life. The appearance of normal teeth is eagerly awaited by the parents since it represents an important early milestone in development. In most cases eruption of teeth causes no distress to the child or parents, but sometimes the process causes local
irritation, which is usually minor but which may be severe enough to interfere with the child’s sleep.

CLINICAL FEATURES OF TEETHING

LOCAL SIGNS

1. Hyperemia or swelling of the mucosa overlying theerupting teeth.
2. Patches of erythema on the cheeks.
3. Flushing may also occur in the skin of the adjacen cheek.

SYSTEMIC SIGNS

1.General irritability and crying
2.Loss of appetit.

3.Sleeplessness

4.Increased salivation and drooling

5.Insanity
6.Meningitis

7.Increased thirst
8.Circumoral rash
9.Cough

Associated Problems
Systemic

Fever,convsions, diarrhea,vomiting, bronchitis, cholera, tetanus

Local

Eruption hematoma, eruption sequestrum, ectopic eruption, transmigration , transposition

MANAGEMENT

PREVENTIVE MEASURES

1. Maintain child’s oral and general body health.

2.Gums should be wiped after each meal with cotton soaked in a weak antiseptic.

3. Adequate quantities of vitamins, minerals , proteins, are given to the child for increasing body’s resistance .

GENERAL MANAGEMENT

1. Hard , non sweetened rusks

2. Use of toasted bread helps in providing gingival stimulation.

3. Use of hard fruits such as appleor guava .

MEDICAL MANAGEMENT

demulcent and mild antiseptic.

1. Topical application of glycerin: It acts as a protective demulcent and mild antiseptic.
2. Topical application of lignocaine hydrochloride which provide relief in the interval before the analgesic is effective .
3. Topical application of benzyl alcohol can also be effective.

SURGICAL MANAGEMENT

Surgical treatment is sometimes recommended for the relief of pain from an eruption cyst or a hematoma. The technique advocates is to make 2 semilinar incisions over the crowns of the tooth , which meet at their extremities. The intervening portion of the tissue , which lies over the occlusal surface of unerupted tooth is then removed with a pair of tissue foreceps.

REFERENCES:TEXTBOOK OF PEDODONTICS SHOBHA TANDON 2ND EDITION