Utility of Tolvaptan in the Perioperative Management of Severe Hyponatremia During Liver Transplantation: A Case Report.

Severe hyponatremia can complicate the pretransplantation management of patients with decompensated cirrhosis while they await liver transplantation. Before the liver transplant, it is critical to correct severe hyponatremia to an appropriate level to reduce the risks of perioperative complications such as central pontine myelinolysis, cerebral edema, and seizures. Vasopressin receptor antagonists, and in particular tolvaptan, offer a therapeutic modality that can correct severe refractory hyponatremia in a timely and predictable manner before liver transplantation. In this case report, we describe a patient with decompensated cirrhosis and severe hyponatremia in whom administration of tolvaptan led to an optimal correction of preoperative severe hyponatremia and allowed for successful liver transplantation with no associated postoperative complications. In light of the increasing pretransplantation disease severity and higher risk of severe hyponatremia, the use of tolvaptan in the pretransplant period may gain increasing importance as a therapeutic intervention for maintaining peritransplant sodium homeostasis.

Comparison of Post-Liver Transplantation Outcomes in Portopulmonary Hypertension and Pulmonary Venous Hypertension: A Single-Center Experience.

BACKGROUND: In potential liver transplant candidates, pulmonary vascular diseases, including portopulmonary hypertension (PoPH) and pulmonary venous hypertension (PVH), can be associated with high morbidity and mortality. Although there are clear guidelines regarding management and transplant listing criteria for patients with PoPH, the listing criteria for PVH are not well defined. OBJECTIVE: The aim of this study was to describe and compare the perioperative and postoperative morbidity and mortality associated with PoPH and PVH in patients undergoing liver transplantation. METHODS: We conducted a retrospective observational study of all patients referred for liver transplantation to our center between 2005 and 2015 who underwent a right heart catheterization (RHC) for screening for pulmonary hypertension as suggested by initial echocardiography. Based on the RHC data, the patients were grouped into no pulmonary hypertension (No PH), PoPH, and PVH categories. In patients who underwent liver transplantation, we recorded vital status intraoperatively and at 30 days and 1-year post-transplant, and we recorded the incidence of postoperative cardiopulmonary and renal complications. RESULTS: Of the 134 patients who underwent RHC as part of the initial transplant evaluation, 50 patients were successfully transplanted. There was 1 intraoperative death in the PoPH group. No significant difference in mortality was noted between the No PH, PoPH, and PVH groups intraoperatively and 30 days after liver transplantation. At 1 year, the survival rates were 100%, 69.2%, and 94.1% in the No PH, PoPH, and PVH groups, respectively. With respect to cardiopulmonary and renal complications, no statistically significant difference was noted among the groups, though there was a trend toward increased post-transplant reversible pulmonary complications in the PVH group. CONCLUSION: Our findings suggest that the post-transplant outcomes of patients with PoPH and PVH are similar. In light of the growing recognition of diastolic dysfunction and cirrhotic cardiomyopathy in decompensated cirrhotic patients at the time of transplant, the issue of pulmonary hypertension related to PVH will gain increasing importance as we assess these patients for transplantation. Therefore, future studies are needed to define evidence based guidelines to determine candidacy for liver transplantation in the context of PVH.

Scalpel versus electrosurgery: Comparison of gingival perfusion status using ultrasound Doppler flowmetry.

The main prerequisites of any surgical procedure are achievement of good visibility and access to the site with minimal bleeding and rapid and painless healing. With the advancement of technology the armamentarium for oral surgical procedures has also widened. The use of alternate methods to the traditional scalpel such as electrosurgery, laser, and chemicals has been widely experimented with. This article aims to report the gingival perfusion pre-operatively and post-operatively, comparing the use of scalpel and electrosurgery in different anatomic sites in patient. Since wound healing is influenced by its revascularization rate, which follows the pattern of new connective tissue formation, the perfusion status of the gingiva has been studied using ultrasound spectral Doppler. The results of our study show that there was 30% more blood flow by 7(th) day, 19% more blood flow by 15(th) day and 11% more blood flow by 30(th) day in sites where the scalpel was used compared with sites where electrosurgery technique was used.

Chemical characterization, mineral analysis, and antioxidant potential of two underutilized berries (Carissa carandus and Eleagnus conferta) from the Western Ghats of India.

Diversity needs to be "conserved through use." Owing to the global need, the present study includes two underutilized berries, Carissa carandus and Eleagnus conferta, to explore their potential as supplementary food by evaluating their antioxidant activity and approximate chemical composition. Berries of E. conferta are a richer source of carotene, ascorbic acid, protein, and magnesium, whereas berries of C. carandus are rich in sugars, lipids, iron, and magnesium. The antioxidant properties of the berries and a comparative account on their performance using DPPH and FRAP assay was studied. Both assays revealed high activity in the peel extract of berries of C. carandus. The LC-MS/MS profile of C. carandus reveals the presence of eleven different polyphenolic compounds while E. conferta had only four of these compounds.

Evaluation of oral submucous fibrosis using ultrasonographic technique: a new diagnostic tool.

AIM: The aim of this study is to evaluate oral submucous fibrosis (OSMF) by clinical and histopathological examination, and compare the results with those from ultrasonographic technique. MATERIALS AND METHODS: 30 clinically diagnosed OSMF patients were subjected to both ultrasonographic and histopathological evaluation before treatment. Later, only ultrasonographical examination was done during 4 th and 8 th week of treatment. Prognosis of the lesion for the treatment was evaluated. Peak systolic velocity (PSV) of blood in the lesional area was statistically analyzed. 10 normal individuals without any mucosal lesions were considered as the control group. RESULTS: In normal individuals, ultrasonography delineates normal mucosa with uniform fine mottled appearance with interspersed hypoechoic areas. Color Doppler and spectral Doppler depicts uniform distribution of blood vessels and normal peak systolic velocity of blood respectively. All OSMF patients were diagnosed upon clinical and histopathological examination. Clinical examination revealed 14 individuals with unilateral palpable fibrotic bands and 16 individuals with bilateral fibrotic bands whereas, ultrasonographic evaluation revealed 6 individuals with unilateral fibrotic bands and 24 individuals were with bilateral fibrotic bands, which was statistically significant. Ultrasonography demonstrated number, length and thickness of the fibrotic bands. Color Doppler and spectral Doppler showed decreased vascularity and PSV in lesional area. Prognosis evaluation revealed 25 cases of good prognosis and 5 cases were showed poor prognosis. Wilcoxon Signed Ranks Test revealed no significant difference of PSV was seen in poor prognosis patients. CONCLUSION: Ultrasonography is a non-invasive diagnostic tool for OSMF. It could be a better diagnostic tool compared to clinical and histopathological examination.

Antiaflatoxigenic and antioxidant activity of an essential oil from Ageratum conyzoides L.

BACKGROUND: Aflatoxin contamination of various commodities can occur as a result of infection, mainly by Aspergillus flavus and Aspergillus parasiticus. Every year, almost 25% of the world's food supply is contaminated by mycotoxins. Aflatoxins B(1), B(2), G(1) and G(2), which occur naturally, are significant contaminants of a wide variety of commodities. A number of biological activities have been associated with Ageratum conyzoides. We have therefore investigated the antiaflatoxigenic, antioxidant and antimicrobial activity of essential oils of A. conyzoides. This could help to turn A. conyzoides, a nuisance weed, into a resource. RESULTS: The essential oil of Ageratum conyzoides L. shows the presence of 12 compounds when analyzed by gas chromatography-mass spectrometry. The growth and aflatoxin production of the toxigenic strain Aspergillus parasiticus was completely inhibited by essential oil. All the studied concentrations of the oil demonstrate a reduction in mycelia growth and decreased production of different aflatoxins in fungi, as revealed by liquid chomatographic-tandem mass spectrometric analysis. Volatiles from macerated green leaf tissue of A. conyzoides were also effective against A. parasiticus. The strongest antibacterial activity was observed against the bacteria Staphylococcus aureus and Bacillus subtilis in a disk diffusion bioassay. Essential oil and methanol extract of A. conyzoides L. were assayed for their antioxidant activity. Methanol extract showed the highest antioxidant activity in FRAP and DPPH assay, whereas essential oil showed greater lipid peroxidation inhibition than methanol extract. CONCLUSION: The plant's ethno-medicinal importance, antioxidant potential, inhibitory activity against the Aspergillus group of fungi and production of aflatoxins may add a new dimension to its usefulness in the protection of stored product.

Synthesis and morphological studies of nanocrystalline MOR type zeolite material.

A number of nanosize mordenite (MOR) analogues with particle size ranging from 5 to 50 nm were synthesized by the hydrothermal method. The effect of various growth parameters like: alkalinity of the medium, type of silica source, etc. on crystal morphology and the crystal size of MOR type of zeolites was investigated. Specific surface and micropore volume were investigated by the Brunauer-Emmett-Teller (BET) method. XRD, SEM, TEM studies indicate nanosize growth of the MOR type crystals. Electron diffraction patterns confirm the crystalline nature of the nanoparticles and the results of their indexing prove that the material is MOR. These synthesized materials show microporous as well mesoporous character. In the case of MOR material synthesized using sodium silicate, it was found that an increase in the alkalinity of the medium led to changes in the morphology and crystal size of the material. For low concentrations of NaOH, the crystallites were spherical in shape whereas at high concentrations, they were in the shape of nanorods of diameter 25 to 50 nm. The morphology of the MOR material synthesized using tetraethyl orthosilicate (TEOS), on the other hand, did not change when the NaOH concentration was increased beyond 2.0 molar.

Bioremediation of oil sludge-contaminated soil.

Bioremediation has become an important method for the restoration of oil-polluted environments by the use of indigenous or selected microbial flora. Several factors such as aeration, use of inorganic nutrients or fertilizers and the type of microbial species play a major role in the remediation of oil-contaminated sites. Experiments were undertaken for bioremediation of oil sludge-contaminated soil in the presence of a bacterial consortium, inorganic nutrients, compost and a bulking agent (wheat bran). Experiments were conducted in glass troughs for the 90-day period. Bulked soil showed more rapid degradation of oil compared to all other amendments. During the experimental period, wheat bran-amended soil showed 76% hydrocarbon removal compared to 66% in the case of inorganic nutrients-amended soil. A corresponding increase in the number of bacterial populations was also noticed. Addition of the bacterial consortium in different amendments significantly enhanced the removal of oil from the petroleum sludge from different treatment units.

Long-term use of clobazam in the management of intractable epilepsy : a prospective study.

Clobazam, a 1-5 benzodiazepine, was used as add-on in the management of intractable epilepsy prospectively from 1993-1996. Forty patients who satisfied the defined inclusion and exclusion criteria with minimum one year follow-up were included. Therewere 25 male and 15 female patients, which included 15 children (37.5 ) and 25 adults (62.5 ). They had epilepsy for a mean period of 145.3 ? 106.9 months. Majority had uncontrolled complex partial seizures with or without secondary generalization. 55had single type of epilepsy and 45 had multiple type of seizures. Clobazam (Frisium) was added as an adjuvant in the dose of 5-30 mg. Patients were followed regularly to evaluate its efficacy and toxic effects. Follow up ranged from 12-66 months with amean of 27.2 ? 13 months. Twelve patients (30) were totally free from seizure, 16 (40) had more than 75 reduction in frequency and 6 (15) had no effect. Tolerance was seen in 7 ( 17.5) patients. This could be managed by increasing the dosage in a step-wise manner. Three female patients complained of increase in weight which has not been reported in the literature so far. We could reduce the dose of other antiepileptics in all and stopped one AED in 8 patients. Clobazam is recently introduced in the Indian market and relatively very economical compared to other newer antiepileptic drugs and effective as first line add-on drug in the management of refractory epilepsy in both adults and children.

Determinants of maternal mortality: a hospital based study from south India.

PIP: During 1981-1986, 86 maternal deaths transpired at the obstetrics department of the Jawaharlal Institute of Postgraduate Medical Education and Research in Pondicherry, India. The maternal mortality rate stood at 5.8/1000 births. 31.4% were primigravidae. The percentage of maternal deaths characterized as gravidae 2-4, 5, and multigravidae was 42.9%, 9.3%, and 16.4%, respectively. The leading causes of death were sepsis (41.9%), especially septic abortion (30.2%); eclampsia-severe preeclampsia (10.5%); ruptured uterus (9.3%); and hemorrhage and prolonged labor (8.1% each). Direct obstetric causes of death accounted for 81.4% of all maternal deaths. Indirect obstetric causes of death were hepatitis (5.8%), heart disease (4.7%), and severe anemia (2.3%). Most of the women who died were illiterate (97.6%), poor (98.8%), and had received no prenatal care (94.2%). 47.7% traveled more than 60 km to the hospital. Quacks or untrained traditional birth attendants had excessively interfered with about 33% before they reached the hospital, especially the septic induced abortion, obstructed labor, and ruptured uterus cases. Among the 48 women who delivered before dying, there were 24 live births (5 of whom died during the early neonatal period) and 24 still births. These findings indicate a need for a cooperative effort to improve and expand maternal and child health care in the community.^ieng

Audit in maternal and child health.

Audit in medicine is a well tried means of assessing the quality of practice by using acceptable measures of outcome. Audit in maternal and child health has been limited to fatal outcomes such as maternal and perinatal deaths. The outcome of audit is of interest to the providers, the health authorities and the consumers. The utility of audit lies in effective use of data to improve quality of service. Quality control of instruments and education of junior staff are some other benefits of audit. The limitations of manpower, money, means, fear of litigation and above all dislike of clinicians for handling data are hurdles in the way of effective audit. The concept of 'Standard Primipara' and 'Total Fetal Wastage' are likely to add new dimension to perinatal audit.

Secondary abdominal pregnancy.

Advanced abdominal pregnancy is a rare event with a high fetal and maternal morbidity and mortality. We present 3 cases of abdominal pregnancy seen at our hospital. The perinatal mortality was 100% with no maternal deaths. Literature has been reviewed and management of abdominal pregnancy is discussed. Awareness of this condition and its clinical features is important in preventing abdominal pregnancy related morbidity, mortality. Careful clinical examination coupled with investigatory aids like X-rays and ultrasound will clinch the diagnosis. Most of the patients require early laparotomy following diagnosis and the morbidity and mortality are high particularly for the fetus.

Two cases of gas gangrene complicating uterine rupture and fetal death at term.

Two patients with obstructed labor and uterine rupture complicated by clostridial septicemia are reported. The diagnosis was apparent clinically. The importance of early diagnosis and prompt treatment are emphasized. The place of hysterectomy, which should be individualized is discussed. All efforts should be directed towards prophylaxis in high risk cases.

How safe is motherhood in India?

PIP: Strategies for reducing maternal mortality in India are suggested for prioritizing maternal and child health (MCH) nationally, for including MCH within welfare services, and for integrating vertical programs into MCH. Attention should be directed to delivery practices and facilities, which account for most of maternal mortality. Clean and well-equipped labor huts which provide quality care should be available in each community. High-risk patients should be housed in maternity waiting homes located near hospitals. Improvements should be made in provision of quality prenatal care in villages, primary health care, and evaluation of services. A focus on family planning targets is not sufficient. Postpartum care programs should function as centers for family activities. A national blood transfusion network should be examined as a feasible plan. All government vehicles should be at the disposal of emergency situations. Home science books for prospective mothers should include chapters on pregnancy, childbirth, and care of the newborn. Television serials hold promise as useful tools for mass health education. Medical students in Departments of Gynecology and Obstetrics should spend 66% of their training time in obstetrics and practical skills in childbirth and newborn care. Regional centers for research and evaluation should be established by the Council on Medical Research. The right to safe motherhood should be assured. A nationwide study conducted in the late 1970s found that maternal mortality was 753/100,000 deliveries. A hospital-based study in 1982-83 found that there were 133 maternal deaths/32,812 deliveries, a maternal mortality rate of 405/100,000 live births. 58.8% of maternal deaths were attributed to obstetric causes: 12.8% to hemorrhage, 17.3% to infection, 12% to hypertensive disorders, 8.3% to ruptured uterus. An additional 15.8% of deaths were caused by hepatitis and 7.5% by anemia. Indian maternal mortality in one week equals the total maternal mortality in all of Europe in one year.^ieng

Destructive operations in modern obstetrics in a developing country at tertiary level.

PIP: In southern India, obstetricians conducted a retrospective study of 33 destructive obstetric operations performed between 1981 and 1991 at Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) in Pondicherry. The mothers were all under 40 years old. The operations included 27 craniotomies, 2 decapitations, 3 eviscerations, and 1 cleidotomy (surgical division of the fetus' clavicle to facilitate delivery). Women with shoulder presentation and hand or cord prolapse tended to arrive at the hospital before full cervical dilatation so obstetricians preferred performing a cesarean section, regardless of viability of the fetus, explaining the low rate of decapitation and evisceration. Yet, obstetricians and primary health center physicians referred most women with cephalic presentation rather late in labor with indications of an important rupture or ruptured uterus. Reasons for craniotomy were hydrocephalus (52%), obstructed labor (19%), arrest of aftercoming head (7%), cord prolapse (5%), persistent meuto-transverse position (4%), and placental abruption (4%). 3 cases had to undergo Cesarean section after other procedures failed. 6% of the women suffered vaginal laceration. 3% experienced fever, urinary tract infection, episiotomy, wound infections, or paralytic ileus. 1 woman died from postpartum hemorrhage and another died from severe postoperative shock after undergoing lower segment cesarean section. The incidence rate of destructive operations was lower than that of other Indian hospitals (all deliveries, .094% vs. .24-.283%). These findings suggested that obstetricians and primary healthy center physicians need to be trained in doing confidentially performed craniotomy, decapitation, or evisceration in rural areas so they do not refer mothers at high risk of ruptured uterus and subsequent death while in transmit to a referral center.^ieng

Internal iliac artery ligation in obstetrics and gynecology. Ten years experience.

Twenty-two cases of bilateral internal iliac artery ligation done in the Department of Obstetrics and Gynecology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India over a period of 10 years (1981-1990) were studied. Various indications and complications were analysed. Internal iliac artery ligation is a life-saving procedure in pelvic hemorrhage. Complications are infrequents.

Prospective analysis of short course chemotherapy in female genital tuberculosis.

Short course chemotherapy with 2SHRZ/7HR of 9 months duration was given in 41 proven cases of female genital tuberculosis. Thirty-two (78%) patients completed 9 months of therapy. Twenty-five (61%) were pronounced cured. Short course chemotherapy appears to be quite effective in patients of genital tract tuberculosis.