Lessons from look-back in acute liver failure? A single centre experience of 3300 patients.

BACKGROUND & AIMS: Acute liver failure (ALF) is a rapidly progressive critical illness with high mortality. Complex intensive care unit (ICU) protocols and emergency liver transplantation (ELT) are now often available, but rarity and severity of illness have limited its study and evidence-base for care. We reviewed patients treated over a 35-year period at a specialist high-volume ICU, quantifying changes in disease aetiology, severity and evolution of ICU support and ELT use and outcome. METHODS: Review of adult patients admitted during the period 1973-2008, with acute liver dysfunction and coagulopathy with overt hepatic encephalopathy (ALF) and those without (acute liver injury; ALI). RESULTS: 3305 patients fulfilled inclusion criteria, 2095 with ALF. Overall hospital survival increased from 30% in 1973-78 to 76% in 2004-08; in ALF from 17% to 62% (both p<0.0001). In ALF patients treated without ELT, survival rose from 17% to 48% (p<0.0001); in those undergoing ELT (n=387) from 56% in 1984-88 to 86% in 2004-08 (p<0.01). Coincident with drug sales-restriction, paracetamol-related admissions fell significantly. Viral admissions fell from 56% to 17% of non-paracetamol cases (p<0.0001). Admission markers of liver injury severity fell significantly and the proportion of patients with intracranial hypertension (ICH) fell from 76% in 1984-88 to 20% in 2004-08 (p<0.0001). In those with ICH, mortality fell from 95% to 55% (p<0.0001). CONCLUSIONS: The nature and outcome of ALF have transformed over 35 years, with major improvements in survival and a fall in prevalence of cerebral oedema and ICH, likely consequent upon earlier illness recognition, improved ICU care, and use of ELT.

Serum selenium levels in patients with head and neck cancer.

OBJECTIVE: The objective of this research was to estimate serum selenium levels in patients with head and neck cancer and to correlate them with tumour burden, as well as to study the effect of radiotherapy on serum selenium levels to determine its prognostic significance. DESIGN: This prospective study was carried out by selection of head and neck cancer patients using periodic random numbers. SETTING: This was a hospital-based study. METHODS: Estimation of serum selenium was done using the Atomic Absorption Spectrophotometer (Model AAS 4129; Electronic Corporation of India Ltd., Hydrabad, India) with a hydride generator after digestion of the serum sample. MAIN OUTCOME MEASURES: Patients were followed for 1 year postradiotherapy for any change in serum selenium level and its correlation with the outcome of the treatment. RESULTS: All 30 patients had serum selenium levels significantly lower as compared with controls, and these levels decreased further as tumour burden increased. Levels came within normal range after 1 year of radiotherapy in 10 patients who were cured but in the remaining patients who had residual disease, levels remained persistently low. CONCLUSIONS: The serum selenium level may serve as a useful marker in head and neck cancer.