Molecular adsorbent recirculating system: albumin dialysis-based extracorporeal liver assist device

Extracorporeal liver assist devices have been used for more than five decades to support patients with liver failure. Numerous modifications have been made to both biological as well as mechanical liver assist devices. Possibly, an ideal liver assist device would be one that would perform optimal detoxification and synthetic functions of the liver, be simple to set up and yet be cost-effective. An albumin dialysis-based device that uses a hybrid albumin-impregnated membrane to get rid of albumin-bound toxins that circulate in abundance in liver failure, called the molecular adsorbent recirculating system (MARS) has been in clinical use for nearly four years now. Results with the use of this device in both acute and acute-on-chronic liver failure have shown consistent improvement in biochemical profile, resolution of encephalopathy, correction in hemodynamics, reduction in intracranial pressure and some improvement in the synthetic function of the liver. In a number of studies, albeit of small sample size, survival advantage has also been observed. The timing of initiation of therapy with MARS, duration of treatment, frequency of sessions and 'maintenance therapy' are still some of the unresolved issues with the use of this device. Large multicentric trials on the use of this technique are expected to throw light on these issues and help optimize the potential of this liver assist device.     

Routine blood counts in children with acute lymphoblastic leukaemia after completion of therapy: are they necessary?

Children who have completed treatment for acute lymphoblastic leukaemia (ALL) are commonly followed up for the first 5 years with regular full blood counts (FBCs) to monitor for relapse of disease. There is little evidence to suggest that this practice improves the detection rate of unexpected relapse. Surveillance FBCs, performed on 43 children with relapsed ALL between 1990 and 1999, were analysed. Of the 42 relapses in children off therapy, only two were detected by an abnormal FBC. Routine FBCs in asymptomatic children off therapy lacks specificity in detecting unexpected relapses and maybe safely discontinued.     

Herpes zoster infection: a rare cause of acute urinary retention

Herpes zoster (HZ) infection has been reported as a rare cause of acute urinary retention. HZ infection involving sacral, thoracolumbar, and rarely high thoracic dermatomes is believed to occasionally cause motor and sensory neuropathy of the bladder. This is specifically achieved by the interruption of the detrusor reflex causing subsequent bladder atonia. As the course and management of this entity is quite benign, HZ should remain a diagnostic consideration in the management of urinary retention. We report a case of acute urinary retention of approximately 2.5 liters associated with HZ infection and review the proposed pathogenesis and therapeutic considerations in the management of this entity.     

Ethical issues in public health policy

Ethics in public health policy is given the least importance and rarely discussed. Resolving ethical issues in public health is often an arduous task as these are complicated and require careful handling. Using four case studies, we discuss issues pertaining to pertussis and brain damage, water fluoridation and dental caries, infection with the human immunodeficiency virus and the right to marriage, and the debate surrounding universal salt iodization. The core issue in all these examples pertains to the relevance of ethics in public health policy.     

Redox reactions of tocopherol monoglucoside in aqueous solutions: a pulse radiolysis study

The reactions between tocopherol monoglucoside (TMG), a water-soluble vitamin-E derivative, with Br2.-, N3., (SCN)2.-, NO2., OH. and various halogenated peroxyl radicals were examined using a pulse radiolysis technique. The results demonstrate that TMG forms a stable phenoxyl radical at pH > 6.8. The thus-formed phenoxyl radical shows pH-dependent decay kinetics and is disproportionated by 2nd order kinetics at pH 2.3. It was observed that the TMG reactivity towards a halogenated peroxyl radical increases with the number of halogen atoms at the carbon atom having a peroxyl group. The reaction between the TMG phenoxyl radical and ascorbic acid was also examined using a pulse radiolysis technique. The results indicate that the TMG phenoxyl radical is repaired by ascorbate. Kinetic studies indicate that TMG may act as an antioxidant to repair free-radical damage to some biologically important compounds. The one-electron reduction potential for TMG was found to be 0.522 V +/- 0.06 vs. NHE.     

Management of persistent atrial fibrillation following balloon mitral valvotomy: safety and efficacy of low-dose amiodarone

BACKGROUND AND AIM OF THE STUDY: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia encountered in clinical practice. In developing countries, rheumatic mitral stenosis (MS) is the most frequent underlying condition in patients with AF. Sinus rhythm (SR) is difficult to achieve and maintain in these patients, but would be more easily achieved with reduction of left atrial pressure after successful balloon mitral valvotomy (BMV). METHODS: Eighty-five patients with persistent AF following BMV received amiodarone (600 mg once daily for two weeks, 200 mg daily thereafter). Electrical cardioversion was performed in those with persistent AF (at six and 12 weeks of drug therapy). RESULTS: Among patients, 33 (39%) converted with amiodarone alone. Of 52 patients who underwent cardioversion at six weeks, 41 (79%) converted to SR. Overall, 87% of patients converted to SR. None of the 11 patients with persistent AF could be converted to SR, despite a second attempt with direct current (DC) cardioversion at 12 weeks. Those who converted to SR had significantly shorter AF duration (AFD) (2.7+/-1.1 versus 3.2+/-0.7 years) and smaller left atrial (LA) size (50.0+/-7.7 versus 57.9+/-4.7 mm). Patient age, gender, NYHA class, ejection fraction and post-BMV variables were comparable between the two groups. Successful maintenance of SR was possible in 61/74 (82%) patients at a mean follow up of 30.6+/-7.1 months (range: 16-43 months). Again, mean AFD was shorter (1.8+/-0.6 versus 3.0+/-0.7 years) and LA size smaller (48.9+/-7.5 versus 54.7+/-6.9 mm) among those who maintained SR. However, even in patients with AFD > or =2 years, successful conversion and maintenance of SR was possible in 74% and 62% of patients, respectively. Among patients with LA size > or =60 mm (n = 16), the corresponding value were 84% and 77%, respectively. On multivariate analysis, only AFD was a predictor of acute and long-term success. The probability of SR remaining in those with AFD <2 years at 21, 30 and 43 months was 96%, 95% and 94.6%, respectively, while for those with AFD > or =2 years these values were 62%, 48% and 40%. CONCLUSION: Low-dose amiodarone was safe and effective in restoring and maintaining SR in patients with AF and rheumatic heart disease.     

Harmonic scalpel tonsillectomy: a prospective study

The harmonic scalpel has been in use for tonsillectomy for the last 5–6 years in western Europe and North America. Although some studies have found this technique to be superior to other conventional methods, its use is still not very popular. In this single-blinded prospective study, the intraoperative events and postoperative morbidity after the use of harmonic scalpel in tonsillectomy (HST) was evaluated in 180 cases in two hospitals and compared with conventional steel tonsillectomy (CST) and hemostasis secured by bipolar diathermy or ligatures in 100 cases. Both bipolar diathermy and ligatures were used to control the intraoperative bleeding in all cases of CST and some cases ( n =9) of HST. The study was done in two hospitals. Patients were randomized irrespectively of their age, sex, past history or indication for surgery. The total number of patients operated on was 180 for HST and 100 for CST. The surgical duration, intraoperative blood loss and postoperative pain were compared between the patients who only had tonsillectomy done in either group ( n =120 in HST and n =70 in CST). The mean operative time in the HST group was not longer than the CST group, but the intraoperative blood loss was significantly less in the HST group. Postoperative pain was present in all patients in the HST group, but to a lesser extent than in the CST group. There was no major postoperative hemorrhage in the HST group that required surgical attention. HST has the advantage over CST when secondary hemorrhage after tonsillectomy is considered. Thus, following the results of the National Prospective Tonsillectomy Audit (NPTA), it may be safe to say that HST is superior to most other conventional methods in reducing secondary hemorrhage. The use of disposable blades in CST certainly reduces the risk of the transmission of Cruetzfield-Jacob disease (CJD).     

Endoprostatic stents for management of benign prostatic hyperplasia

Endoprostatic stents have been developed for relieving bladder outlet obstruction secondary to benign hyperplasia of the prostate. The stents are designed either for permanent or for temporary placement. The short-term temporary stents of various biostable and biodegradable polymers are needed after minimally invasive therapy of prostate with heat. The temporary stents are a management option, whereas the permanent stents are a treatment option. Permanent stents offer immediate relief and their sustained results for 4-7 years make them ideally suited for medically compromised patients.