Aster Cmi Hospital

The liver is a key metabolic organ and plays a vital role in digestion and absorption of foods. It can be severely diseased or injured due to various causes listed below, and one of the definitive measures of an injured or a diseased liver is a liver transplant. A liver transplant involves removing the failed liver and replacing it with a healthy liver from a donor.

Some reasons requiring liver transplant include:

• Alcoholic liver disease
• Liver cancers or tumors
• Fatty liver disease (non-alcoholic steatohepatitis or NASH)
• Severe hepatitis C
• Severe alcoholic cirrhosis
• Biliary atresia in children
• Acute liver failure

Some of the symptoms that indicate liver failure are:

• Black, tarry stools
• Blood in the vomit
• Fluid accumulation in the abdomen (ascites)
• Jaundice
• Mental confusion
• Tendency to bleed even from minor wounds

There are primarily two types of liver transplant:

• Deceased donor transplants: In a person who is brain dead, the liver can be removed and transplanted into a person who needs a transplant. The entire liver is usually transplanted.
• Living donor transplant: A liver is known for its regenerative properties, and in some people, a part of the liver can be removed and transplanted into another, usually a close family member. The replaced part grows into a full-size liver over a period of time and becomes fully functional.

Anyone with severe liver cirrhosis with a life expectancy of less than a year is usually required to undergo a liver transplant. In terms of survival rates, here are some statistics:

• After a year, more than 90% survive a liver transplant.
• After 5 years, more than 85% survive a liver transplant.
• After 10 years, more than 75% survive a liver transplant.

It is not uncommon for people to survive for more than 10 to 15 years, if they maintain regular follow up and discipline.

Factors affecting survival rates
The overall health status of an individual determines the success rate of a liver transplant. The following are considered to bring down the survival rates:

• Critical illness
• Malnourishment
• Active infection
• Other organ damage such as a kidney failure

Most liver failures start as hepatitis, and when diagnosed early, treatment can be done effectively. However, if left untreated, it can lead to cirrhosis which then requires a liver transplant in most cases.

Evaluation before transplant
A detailed recipient evaluation is done to confirm that liver transplant is indeed required to improve success rates. The following factors are determined:

• Diagnosis and severity of the condition
• Urgency of the transplant
• Overall health status
• Emotional preparation for a transplant

The patient is then placed on the list for a cadaveric transplant. Alternately, if a donor is available, the donor evaluation and transplant is done.

Foot pain contributes around 3-5 % of patients visiting Orthopedic OPD, with heel pain being predominant complaint. Heel pain commonly involves the underside or back of your heel. Although not a symptom of a serious condition, it’s disabling as it can interfere with your routine activities.

Plantar fasciitis, Achilles tendinitis, Heel spur, Retrocalcaneal bursitis are few common conditions causing heel pain.

The below few conditions which are prone to developing heel pain like:

• Abnormal walking style (gait)/altered alignment of the foot
• Obesity
• Ill-fitting shoes/ badly-worn shoes
• Standing, running or jumping on hard surfaces
• Injury to the heel, such as stress fractures
• diabetes and arthritis

The most common causes of heel pain are plantar fasciitis (bottom of the heel) and Achilles tendinitis (back of the heel).

Presenting complaints:

• Pain which is usually intense in the mornings or after a long period of res,
• Discomfort or swelling in the back of your heel
• Skin on your heel overly warm to the touch
• Burning sensation over heel
• Numbness or tingling in your heel
• Swelling around ankle etc

Remedies you can try:

• Avoid activities that aggravate your heels, such as running, standing for long periods or walking on hard surfaces.
• Ice application on your heel for 10-15 minutes at least three times a day.
• Well fitting shoes.
• Non-steroidal antinflammatory drugs can reduce inflammation and pain
• A splint is worn at night
• Flexibility exercises

Prevention of heel pain:

• Wear a well-fitting & comfortable shoe
• Always warm up and cool down when exercising or playing
• Silicone insoles

Consult your doctor immediately if, Heel pain persists in spite of home remedies. Try these tips to put Heel pain at rest!

Liver transplants are considered a safe procedure and has a high success rate. However, it is important for patients to follow proper aftercare instructions as given by the doctor. The liver helps process food and filter toxins and hence the patient’s diet must be carefully monitored after a transplant surgery. Weight gain after liver transplant can cause fatty liver disease and damage the sensitive transplanted liver.

Here are a few tips on the ideal diet to be followed after a liver transplant surgery.

• Avoid alcohol: Alcohol is a big no-no after a liver transplant surgery. In addition to not drinking any type of alcohol, patients should also abstain from any food cooked in alcohol or wine.
• Avoid pomegranates and grapefruits: Fruits are very good for recovery but certain fruits such as pomegranates and grapefruits should be avoided. This is because they may have an effect on the immunosuppression medications being prescribed to keep the body from rejecting the donor liver.
• Eat plenty of vegetables: Vegetables are essential during recovery process after a transplant surgery. This gives the body the necessary nutrition it requires and also acts as a good source of fibre.
• Eat lean meat: Lean meats like poultry and fish act as rich sources of proteins. This helps the body speed up the recovery process. Other forms of protein include soy, eggs, legumes and nuts. Avoid fatty meats as these are difficult to digest and can put a strain on the liver.
• Drink plenty of water: Water helps in hydrating the body and is essential during recovery from a major surgery such as a liver transplant. Water also helps improve blood circulation and eases the filtration of toxins. Patients should ideally drink 8-10 glasses of water a day.
• Limit sugar consumption: One of the side effects of medication prescribed after a liver transplant includes high blood sugar. To avoid this, limit your consumption of sweets and sugars. Avoid cakes, jams, jellies, packaged juices and chocolate.
• Have plenty of fibre: Fibre helps ease digestion and helps control cholesterol levels. An increase in cholesterol levels may be due to the medication being prescribed. Hence eat plenty of fibre. This could be in the form of whole grain foods, vegetables and fruits. As far as possible avoid processed foods.
• Get enough calcium: Medication prescribed after a liver transplant may make the patient’s bones lighter. This can increase the risk of conditions such as osteoporosis. To counter this, it is important to get enough calcium.

Before consuming any kinds of foods and supplements, it is essential to consult with the doctor about the diet that needs to be followed. A proper diet and aftercare can do wonders in recovering from the surgical procedure.

The liver plays an important role in the digestion process and filtration of toxins from the body. In rare cases, a person with no history of liver problems may suddenly begin to show symptoms of decreased liver functioning. If this deteriorates quickly over a few days or weeks, it is known as acute liver failure. This condition is also known as fulminant hepatic failure. If left untreated, it can cause a number of fatal complications including excessive pressure on the brain and uncontrollable bleeding.

Treatment for acute liver failure depends on the factors triggering the condition.

• If it is caused by an overdose of certain medication, the condition can be reversed. In such cases, medication is the first form of treatment. Similarly, acute liver failure caused by poisoning may also be reversed with medication. These medications help control and reverse the effect of the toxins and thus reduce liver damage. Acute viral hepatitis is the commonest cause of acute liver failure in India.
• If the condition cannot be reversed, a liver transplant may be the only available form of treatment. This surgery is considered a relatively safe procedure and has proved to be very effective in treating acute liver failure.
• A liver transplant involves removing the damaged liver and replacing it with a healthy liver from a cadaver donor or part of a healthy liver from a living donor. Earlier it was only children who could be treated by transplanting a part of liver donated by a living family member. But in the recent years, there are many patients that are being treated by the same procedure.
• By receiving a liver transplant from a living donor, patients do not have to be placed on the waitlist for a liver and thus have a higher survival rate. To be a living donor, the person must have the same blood type as the patient, must be healthy enough to undergo surgery and must have a liver that is large enough to be divided into two parts.

A liver transplant procedure is performed while the patient is under general anaesthesia. Hospitalization is required after the procedure for the doctor to see that the incision is healing properly and to ensure that the body does not reject the transplanted liver. To reduce chances of a rejection, the patient is given medication to suppress the immune system. Hence, it is very important for the patients to stay in a hygienic environment and reduce their exposure to infections.

The liver has a significant role to play in metabolism and digestion. The failure of a liver can lead to significant health issues. There are some causes for liver failure, which cannot be treated with medications. In these people, a transplant, which is replacing the diseased or injured liver with another liver, is the only definitive treatment option.

Some conditions which can require a liver transplant are:

• Severe cirrhosis with a life expectancy of less than a year
• Severe liver failure
• Non-alcoholic steatohepatitis (NASH)
• Liver cancer
• Chronic hepatitis C
• Biliary atresia in children

Types of transplant:

• Living donor transplant: In some patients, partial liver can be removed from a close family member and transplanted into the affected individual. The liver is known for its regeneration ability, and over time, will grow in the recipient.
• Cadaveric transplant: Immediately after death, a liver can be removed and transplanted.

While the concept of a transplant sounds quite convincing and appealing for those with a severe liver disease, it is also important to note that not all would qualify for a liver transplant. The conditions which would disqualify a recipient are discussed below:

• Significant heart disease: Those with severe coronary artery disease, valvular disease, cardiomyopathy, aortic stenosis, and cardiomyopathy are not candidates for a liver transplant.
• Severe lung disease: Those with poor lung perfusion do not qualify for a liver transplant.
• Advanced age: Greater the age, lesser the survival rates. So, people aged more than 70 are usually not considered for a transplant.
• Obesity: A person with a BMI of more than 35 is often not a good candidate for a transplant. The overall health should be managed in these people.
• Malnutrition: On the other extreme, severely malnourished individuals are also not considered for a transplant.
• HIV infection: A person who is HIV-infected does not qualify for a liver transplant.
• Substance abuse: Anyone who is actively abusing alcohol and/or substances is definitely removed from the list for a transplant.
• Metastasis: If a patient is looking for a liver transplant due to hepatic cancer, it is essential that the cancer is contained. If it has spread to various parts, then containing it would be difficult, and a transplant may not succeed.
• Multisystem organ failure: Other than heart and lungs, even people with poor renal function are not ideal candidates for a liver transplant.

A detailed liver recipient evaluation assessing the severity of liver disease, chances of survival, and overall health are done before a person is listed for liver transplant. This evaluation ensures a better success rate with the transplant.

A liver is the largest organ in the human body, weighing about 1.5 kg and has a significant role in terms of digestion and metabolism. It also helps remove toxins and fight infections. Therefore, when a liver fails, the overall health of an individual is significantly affected. Often a liver transplant is required where the affected liver is removed and a new liver from a donor, either living or deceased, is placed and sutured in place. The success rate, if done early and well, can be close to 80% at three years. Over a period of time, this new liver gets accepted by the body to perform various functions that were done by the original liver.

The people affected by the following diseases could benefit significantly from a liver transplant.

• Chronic liver failure: This is not easily identifiable and the condition develops over a period of time, usually over years. Chronic liver failure is produced by many conditions, the most common being cirrhosis. Due to chronic alcohol abuse, the liver tissue undergoes scarring. This scarred tissue replaces the normal liver tissue and the liver functions are affected. This leads to poor metabolism, indigestion, toxin accumulation, etc. The most typical symptoms include accumulation of fluid in the abdomen and black, tarry stools. Once diagnosed, evaluation is done to find out the MELD score. This determines the severity of cirrhosis and overall prognosis. For most cases of severe cirrhosis, transplant is almost a definitive treatment with 3-year survival rates of close to 75%.
• Nonalcoholic steatohepatitis (NASH): People who are not alcohol abusers, but have a fatty accumulation within the liver, often face a liver failure. This again can require a liver transplant.
• Biliary conditions: The bile ducts transport the bile that is produced in the liver to the stomach. If these are not functioning properly, either due to cirrhosis, blockage, or improper development, then a liver transplant may be required. This is often done in younger patients, less than 15 years old.
• Congenital conditions like hemochromatosis and Wilson’s disease: These are genetic conditions, often identified in children, and require a transplant at a young age. A full liver transplant may not be required in these cases.
• Acute liver failure: This is often a side effect of medications and can onset within a few weeks. This can necessitate a liver transplant as in most of the cases, the patients are young.

The liver is the largest organ in a human body and plays a key role by secreting various digestive enzymes and hormones. It also stores various nutrients required by the body and helps fight infection and remove toxins. For various reasons, the liver can fail to perform its function at optimal levels. This can lead to a liver failure, and in severe cases, a transplant may be the most definitive treatment. Liver transplant is when the diseased liver is removed and replaced with a new liver.

There are various types of liver transplants, depending on the donor and the amount of liver transplanted.

1. Living donor: In people with severe liver failure, a close family member is identified who is also willing to donate. A donor evaluation is then done and a part of the liver is removed and transplanted in the patient. The liver, known for its regenerative properties, grows in the recipient, and over a period of time, gets accepted by the recipient.
2. Deceased liver transplant: Also known as an orthotopic liver transplant, this involves removal of the liver from a matched donor and placing it in the affected individual. The liver should be replaced within few hours of death. For people who are expecting a liver transplant, they are often evaluated and placed on a waiting list. Also, a list of those willing to donate is maintained. As soon as a person dies, the potential recipient is called and then a transplant is conducted. In the USA, it could even be years before a donor becomes available. In countries like India, a non-family donation is not legal as it could lead to rackets.
3. Split type or partial transplant: As noted, it is not necessary in some cases that a full liver be available for transplant. A part of the liver can be transplanted in the recipient, and it continues to grow there. Sometimes, the liver from a deceased person is split into a larger and a smaller portion and transplanted in an adult and a child respectively.
4. Auxiliary liver transplantation: In some cases, for instance, in people with a metabolic disease, the recipient’s liver is only partially removed and replaced with a new partial liver. The original liver could be used for gene therapy to help in recovery.

In all these cases, it is very essential to choose an appropriate transplant center and undergo a thorough evaluation to ensure a successful liver transplantation. When properly done, liver transplants have a success rate of 85% in 5 years.

The liver is the engine of the human body. It is basically composed of 2 types of cells (a cell is the basic building block of the human body) – hepatocytes (liver cells) and cholangiocytes (bile duct cells). It also has other supporting tissue and their respective cells. The hepatocytes are by far the most numerous cell type, not surprisingly tumours (otherwise called mass or lump. “Tumor” means lump in Latin), of this cell form the majority of abnormal growths in the liver. Abnormal growths can be benign (that is, they do not grow rapidly, spread to other parts of the organ or to other parts of the body) or malignant (grow rapidly, spread to other parts of the organ and to other parts of the body, i.e. cancer). These abnormal growths from liver cells are Focal nodular hyperplasia (FNH), Adenomas (the benign variety) and hepatocellular cancer (otherwise called Hepatoma/HCC, the cancerous type). What we need to recognize is that certain adenomas can turn into HCC, over a period of time. The other type of growths in the liver are those that have originated elsewhere in the body and spread to the liver, for example a growth of the breast spreading to the liver. These are in fact the commonest tumours of the liver. I will discuss these at a later date.

Benign growths of the liver

Common benign growths are Haemangiomas, FNH and Adenoma. Most of these are identified when a scan is performed as investigation for some other problem. Accurate diagnosis of the nature of these lumps is important to determine the type of treatment needed. This can be ascertained by a carefully selected scan like an Ultrasound, CT scan or an MRI. The technology of these scans is continuing to evolve and get better year on year. There are different types of Ultrasound, CT and MRI scans with different applications, based on whether contrast is used or not, the different phases of scanning, the type of MRI scanning sequence etc. Therefore, these scans although commonly available and used very frequently, need to be performed under the supervision of a team involving Liver doctors and radiologist who is well versed in the diagnosis of liver lumps, for accurate diagnosis without the need for unnecessary tests (Box 1).

Haemangiomas are by far the commonest. It is estimated that 5% of the adult population harbor this lump in their livers! They occur in both sexes and at all ages but are commonest between 30 to 50 years in women. Most of them are small, less than 4-5 cms in diameter and are are identified on Ultrasound. MRI and its various applications is the scan of choice for accurate diagnosis. This is crucial as most of them do not need treatment.

Focal Nodular Hyperplasia (FNH) are the second most common liver lumps. They are usually single and small (less than 4 cms) and occur in women between 35 – 50 years of age. About 2.5-3% of population harbor this lump in their livers. Special MRI techniques using special contrast agents is diagnostic and the findings are quite distinct from haemangiomas. Again treatment is not recommended apart from selected circumstances. Assessment in a dedicated Liver team is recommended for accurate diagnosis and a proper management plan to be formulated.

Hepatic adenomas (Hepatocellular adenoma, HCA) are rare lumps and occur in 0.2 to 0.3% of the population, again occurring mostly in young women during their reproductive period. They are again solitary and most usually 3-4 ms in diameter.

There are a couple characteristics which make this lump different from the previous 2, there is a strong relation between hormones the development of HCA and some of these HCA can turn into the malignant Hepatocellular carcinoma (HCC). Therefore, accurate characterization and diagnosis of these HCA is essential. Sometimes biopsy of the lump, molecular and genetic tests maybe necessary to determine if the HCA has a high chance of progressing to HCC. Imaging tests are generally adequate, contrast MRI Liver and its different techniques is accurate in diagnosing HCA and sub-typing it, however CT and contrast-enhanced Ultrasound is sometimes necessary along with MRI.

Generally, a HCA in a male is recommended for surgical resection. While in women, discontinuation of the OCP pill/ any other such hormone is recommended for a period of 6 months, if the HCA does not have any worrying features and size is less than 5 cms. IF HCA is larger than 5 cms and has features suggestive of a high risk for change to HCC, surgery is advised. Again these decisions have to be made as a part of a Multi-disciplinary team (Box 1)

Malignant growths beginning within the Liver

As mentioned earlier, usually malignant growths which are seen in the liver spread to it from elsewhere in the body. Hepatocellular cancer/Hepatoma (HCC) is the commonest malignant tumour beginning within the liver, as apposed to those that spread to the liver from elsewhere. It occurs between 40-70 years of age and occurs commonly in men. It is estimated that 17000 new patients develop this tumour every year in India. The vast majority (> 80%) of these develop in patients who have chronic liver disease (cirrhosis). Importantly the number of HCC cases is increasing year on year as cirrhosis due to fatty liver disease, Hepatitis B (3% of Indian population carry this virus, ie nearly 40 million individuals) and alcohol are continuing to increase in India. Nearly overall it is the 4th or 5th most common cause of cancer and the second most common cause of cancer-related death. This is continuing to increase too. We do not have a national policy in India to screen and diagnose these lumps in the liver at an early stage. Most patients present at a late stage when effective treatment is not possible.

Hepatitis B is a vaccine-preventable disease, there are good drugs to treat it and decrease the risk of cirrhosis and HCC in HBV patients, therefore it is important to test for this virus infection. The fatty liver disease can cause chronic liver damage and HCC, regular exercise and consuming a balanced diet can reduce the risk of fatty liver disease.

The usual mode of detection of these growths is when a scan is done for some other reason. Occasionally patients can develop pain in the abdomen or jaundice which leads to an investigation. The treatment of HCC depends on the extent of tumour, the extent of the chronic liver disease (the stage of cirrhosis) and the overall condition of the patient. These patients are best seen, assessed and treated in a team (Box 1) which specializes in the treatment of Liver disease.

The best treatment for HCC is surgery. However, this is suitable only for certain carefully selected patients. This can take the form of liver resection (where a portion of the liver with tumour is removed) or liver transplantation (where the whole liver is removed and a donated liver (full or partial) is replaced into the patient. Indeed surgical has excellent survival rates; more than 75% of patients survive for more than 5 years after resection or transplantation making treatment for these cancers one of the most satisfactory.

Other treatments which can be combined with surgery in selected patients or can be combined with patients not suitable for surgery are different types of Interventional radiological therapy – chemotherapy or radiotherapy delivered through fine catheters introduced into the blood vessels of the liver (TACE: Transarterial chemotherapy, TARE: Transarterial radiotherapy) and or heat energy delivered to the tumour area by means of carefully placed needles/probes (RFA: radiofrequency ablation, MWA: microwave ablation).

HCC is unique cancer as its treatment should be tailored to the patient, the treatments are varied and range from catheter-based non-invasive treatment to major surgery and transplantation. This necessitates that HCC patients are best managed in a multidisciplinary team which is highly skilled in and specializes in the management of liver diseases.

Box 1: A liver tumour multidisciplinary team – Integrated Liver Care team

• The team should be one with expertise in the management of benign liver lesions and should include a Hepatologist, a Hepatobiliary & Transplant surgeon, Diagnostic and Interventional radiologists, Medical oncologist and a Pathologist.

• Each member of the team must hold specific and relevant training, expertise and experience relevant to the management of benign liver lesions.

• The team should be one with the skills required not only to appropriately manage these patients but also to manage the rare but known complications of diagnostic or therapeutic interventions.

In case you have a concern or query you can always consult an expert & get answers to your questions!

A cochlear implant is a small electronic device that can help improve the hearing of people with severe, irreversible hearing loss. Although a cochlear implant does not restore normal hearing, it can allow a person to hear and understand more speech than was possible with a hearing aid.  For a child, this could mean an opportunity to develop listening and speech skills and the potential to attend school with hearing peers. For adults, a cochlear implant could reduce social isolation and improve communication.   

The Implant 
The cochlear implant is a device that is placed in the inner ear.   The implant system has three primary parts:  

1. Microphone and Transmitter —The headpiece and transmitter is worn above the ear to pick up sounds. These sounds are sent to a speech processor.  
2. Speech Processor — A speech processor is worn externally, behind the ear like a hearing aid, to convert sound into a digital code that is transmitted to an implanted stimulator.  
3. Implanted Stimulator — The implanted stimulator is a small component placed under the skin behind the ear. It receives a digital code from the speech processor and sends it to the auditory or hearing nerve. 

The brain interprets this signal and it is recognized as sound.  The small headpiece and transmitter is held in place by a magnet coupled the implanted stimulator, under the skin.  

The Evaluation  
Tests are done to determine if a child is a candidate for a cochlear implantation. Patients are selected based on medical and hearing histories and test results as well as findings.  The evaluation, which differs slightly for children and adults, includes the following:  * 

1. Medical Evaluation — Conducted by the cochlear implant surgeon who will take the medical history, examine your ears and explain the surgical process.
2. CT Scan of the Temporal bone and MRI Brain and Cochlear imaging - This computerized tomography (CT) scan allows the surgeon to evaluate the ear's internal structure, recommend which ear to implant and may provide information as to the cause of deafness.
3. Audiological Evaluation — This evaluation involves a hearing test to confirm the type and degree of hearing loss, hearing aid evaluation to assess the benefit provided by a hearing aid and aided speech recognition testing to determine if a hearing aid might provide greater benefit than an implant.  
4. Psychological Screening — This screening is conducted by psychologist to assess the feelings about hearing loss and the cochlear implant, such as the reasons for seeking the implant and the expectations.  
5. Cochlear Implant Counseling — At this time, if one is a candidate for cochlear implant, possible benefits and limitations will be explained and one will be provided with information to select the device.  

Surgery  
Before the surgery, one will meet with an anesthesiologist and and complete any necessary tests. Patients generally remain in the hospital overnight and return home the day after surgery.  

Implant surgery is performed under general anesthesia and takes about three hours. During the operation, a surgeon will anchor a receiver-stimulator device in the temporal bone in the skull and insert what is called an "electrode array" into the cochlea, the small snail-shaped structure in the inner ear that contains the hearing organ.  First, an incision is made behind the ear to expose the temporal bone. The surgeon then positions the implant component against the bone. A hole is made in the temporal bone with a microscopic drill, allowing the surgeon access to the cochlea. A small hole is made in the wall of the cochlea and the electrode array is gently guided into the cochlea. The internal receiver is secured in place on the skull bone with sutures and the incision is closed. A sterile dressing is placed on the incision.  

To qualify for a cochlear implant, patients must meet the following criteria:  
Adults age 18 and older have:  

1. Overall good health 
2. Severe hearing loss in both ears 
3. Limited benefit from conventional hearing aids determined by a trial period, when appropriate, of about three months  
4. Psychological and emotional stability  
5. Realistic expectations of the implant  
6. No ear conditions or other medical conditions that would interfere with surgery  
7. Ability to participate fully in a follow-up   

Children age 1 to 17 must have:  

1. Overall good health  
2. Severe hearing loss in both ears 
3. Limited benefit from conventional hearing aids  
4. Realistic expectations of the cochlear implant  
5. No ear conditions or other medical conditions that would interfere with surgery  
6. Family commitment to comply with all evaluations before and after surgery  
7. Enrollment in a post-operative rehabilitative and educational program that supports the use of cochlear implants and the development of hearing skills  

Follow-Up 
Following surgery, patient will return home for four weeks to allow time for swelling to subside and the incision to heal. After several days, the incision may be wet during bathing or showering.

Device Programming

The externally worn speech processor is activated about four weeks after surgery. The processor converts speech into a special code for each user. The activation and programming is performed at the Hospital. Programming for each implant is customized for the patient and takes about six hours over a two-day period. 

Testing 
Visit at regular intervals for device checks and re-evaluation. During these visits, the implant and equipment are checked and performance is measured. Re-testing generally occurs at one, three and six months and one year following the initial device fitting. Then, semi-annual or annual evaluations are performed. Each session for adults involves about three hours.  

Outcomes  
Benefit from a cochlear implant usually improves with time but can't be guaranteed. Rehabilitation after surgery is key to maximizing the benefits of the cochlear implant. Most people with these implants are able to engage in hearing activities, such as listening to a Walkman, enjoying a movie, using a phone and participating in social activities.  The motivation is critical to the success of the implant. Use the device during all waking hours, Listen, speak and interact with others as much as possible, Utilize visual cues when adjusting to the implant, but gradually decrease the use of visual cues when ready, Ask others to identify unfamiliar sounds so they become familiar.  

Many people have questions about cochlear implants, how they work and what to expect from the surgery. Here are some common questions and answers-

Will a cochlear implant restore normal hearing for people who are deaf? 
No, a cochlear implant does not restore normal hearing. It is a communication tool but not a "cure" for deafness. When hearing functions normally, parts of the inner ear convert sound waves into electrical impulses. These impulses are sent to the brain, where they are recognized as sound. A cochlear implant simulates that process. An implant, supplemented with listening therapy, can help people recognize sound, including speech.  

Are there risks in cochlear implant surgery?  
Risk is inherent in any surgery requiring general anesthesia. However, the surgical risks for cochlear implantation are minimal and most patients require only a one-day hospital stay and have no surgical complications.

Will I need more surgery as new technology becomes available?  
The implanted unit is designed to last a lifetime. The externally worn speech processor, which is responsible for converting sound into code and sending the information to an internal unit, is dependent on software that can be upgraded as technology improves.  

Will my child outgrow the internal device and require a new one?  
No, the cochlea is fully formed at birth and the skull structures achieve almost full growth by age 2. The electrode array is designed to accommodate skull growth in children.  Should I wait for new cochlear implant technology?  No, the design of the surgically implanted receiver and electrode array has changed relatively little during the history of cochlear implants. However, speech-coding strategies, which are responsible for delivering the signal to the internal unit and are stored in the externally worn speech processor, have improved significantly over the years. The speech processor can incorporate new technology when available.  

Can people with cochlear implants identify environmental noises as well as speech?  
Cochlear implants provide a wide range of sound information. Performance in speech perception testing varies among individuals. With time and training, most patients understand more speech than with hearing aids and many communicate by telephone or enjoy music.  

Can people with cochlear implants swim, shower and participate in sports?  
Yes, people with implants can swim, shower and participate in virtually all types of sport activities when they are not wearing the external equipment. The only restriction relates to skydiving and scuba diving because significant changes in air pressure are not advised. Participation in all other athletic activities is unrestricted, although protective headgear is always recommended.  In case you have a concern or query you can always consult an expert & get answers to your questions!

The liver has a significant role to play in metabolism and digestion. The failure of a liver can lead to significant health issues. There are some causes for liver failure, which cannot be treated with medications. In these people, a transplant, which is replacing the diseased or injured liver with another liver, is the only definitive treatment option.

Some conditions which can require a liver transplant are:

• Severe cirrhosis with a life expectancy of less than a year
• Severe liver failure
• Non-alcoholic steatohepatitis (NASH)
• Liver cancer
• Chronic hepatitis C
• Biliary atresia in children

Types of transplant:

• Living donor transplant: In some patients, partial liver can be removed from a close family member and transplanted into the affected individual. The liver is known for its regeneration ability, and over time, will grow in the recipient.
• Cadaveric transplant: Immediately after death, a liver can be removed and transplanted.

While the concept of a transplant sounds quite convincing and appealing for those with a severe liver disease, it is also important to note that not all would qualify for a liver transplant. The conditions which would disqualify a recipient are discussed below:

• Significant heart disease: Those with severe coronary artery disease, valvular disease, cardiomyopathy, aortic stenosis, and cardiomyopathy are not candidates for a liver transplant.
• Severe lung disease: Those with poor lung perfusion do not qualify for a liver transplant.
• Advanced age: Greater the age, lesser the survival rates. So, people aged more than 70 are usually not considered for a transplant.
• Obesity: A person with a BMI of more than 35 is often not a good candidate for a transplant. The overall health should be managed in these people.
• Malnutrition: On the other extreme, severely malnourished individuals are also not considered for a transplant.
• HIV infection: A person who is HIV-infected does not qualify for a liver transplant.
• Substance abuse: Anyone who is actively abusing alcohol and/or substances is definitely removed from the list for a transplant.
• Metastasis: If a patient is looking for a liver transplant due to hepatic cancer, it is essential that the cancer is contained. If it has spread to various parts, then containing it would be difficult, and a transplant may not succeed.
• Multisystem organ failure: Other than heart and lungs, even people with poor renal function are not ideal candidates for a liver transplant.

A detailed liver recipient evaluation assessing the severity of liver disease, chances of survival, and overall health are done before a person is listed for liver transplant. This evaluation ensures a better success rate with the transplant.