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Dyslipidemias are the most important coronary artery disease (CAD) risk factor. Proper management of dyslipidemia is crucial to control the epidemic of premature CAD in India. Cardiological Society of India strived to develop consensus-based guidelines for better lipid management for CAD prevention and treatment. The executive summary provides a bird's eye-view of the ‘CSI: Clinical Practice Guidelines for Dyslipidemia Management’ published in this issue of the Indian Heart Journal. The summary is focused on the busy clinician and encourages evidence-based management of patients and high-risk individuals. The summary has serialized various aspects of lipid management including epidemiology and categorization of CAD risk. The focus is on management of specific dyslipidemias relevant to India-raised low density lipoprotein (LDL) cholesterol, non-high density lipoprotein cholesterol (non-HDL-C), apolipoproteins, triglycerides and lipoprotein(a). Drug therapies for lipid lowering (statins, non-statin drugs and other pharmaceutical agents) and lifestyle management (dietary interventions, physical activity and yoga) are summarized. Management of dyslipidemias in oft-neglected patient phenotypes-the elderly, young and children, and patients with comorbidities-stroke, peripheral arterial disease, kidney failure, posttransplant, HIV (Human immunodeficiency virus), Covid-19 and familial hypercholesterolemia is also presented. This consensus statement is based on major international guidelines (mainly European) and expert opinion of lipid management leaders from India with focus on the dictum: earlier the better, lower the better, longer the better and together the better. These consensus guidelines cannot replace the individual clinician judgement who remains the sole arbiter in management of the patient.

Peripheral arterial disease (PAD) affects 12 % of adult population and is increasing globally and in India. Peripheral arterial disease when associated with atherosclerosis in two or more other arterial beds such as coronary artery disease (CAD), mesenteric/renal artery and cerebrovascular disease (CVD), is known as polyvascular disease. The Reduction of Atherothrombosis for Continued Health (REACH) registry reported that 1 out of 6 patients had multi-vascular bed involvement. Progression of PAD to critical limb ischaemia (CLI) is seen in 1 % of affected patients per year, but patients who progress to CLI may have a 10- to 15-fold increased risk of cardiovascular death.The 2019 ECS/EAS guidelines for the management of dyslipidaemias have suggested that for primary or secondary prevention in very high risk, patients should follow a therapeutic regimen that achieves >50 % LDL-C reduction from baseline and an LDL-C goal of

Abstract Background There are few case reports in which non-cardiac surgery under regional anesthesia has been described in a patient with a pulmonary artery aneurysm. We report a case in which we managed a 74-year-old lady with a hip fracture for fixation under spinal anesthesia after thorough evaluation and meticulous planning. The patient was discharged home after 5 days without any perioperative events. Case presentation A 74-year-old, hypertensive lady with an incidentally detected pulmonary artery aneurysm was posted for a dynamic hip screw. Two-dimensional echocardiography revealed normal biventricular function with an ejection fraction of 60%, no regional wall motion abnormalities, concentric right ventricular hypertrophy (tricuspid annular plane systolic excursion or TAPSE of 19 mm), severe calcific pulmonary stenosis (PS) with pressures 90/61 mm Hg, pulmonary valve annulus of 12 mm, and pulmonary artery systolic pressure of 35 mm Hg. The left and right pulmonary artery diameters were 17 mm and 20 mm, respectively. She was clinically asymptomatic with an oxygen saturation of 98% on room air. A sequential lumbar epidural anesthesia was planned for this patient given her age, overall frail condition, and to avoid airway instrumentation. As epidural was difficult due to fused spaces, a sub-arachnoid block was administered with continuous monitoring. Surgery was uneventful and the patient was discharged on the 5th postoperative day. Conclusions With this case report, we suggest that a central neuraxial blockade could be administered in presence of severe PS with meticulous monitoring and careful planning.

Objective: To compare the survival and length of stay of invasive ventilation (IV) with those of non-invasive ventilation (NIV) in patients with COVID-19 acute respiratory distress syndrome in a single hospital from May 2020 to March 2021. Methods: After obtaining approval from the Hospital Director, the data of COVID-19 patients including demographics, type of respiratory support (non-invasive ventilation or invasive ventilation), duration of ventilation, length of stay, discharge, and death were collected and analyzed. Results: Out of the 152 patients identified, 134 patients were analyzed. The median intubation days were 10.0 (Q1: 3.5, Q3: 13.5) in the IV group and 0.0 (Q1: 0.0, Q3: 0.0) days in the NIV-only group. Out of the 101 patients who received NIV, 43 patients were subsequently intubated due to failure of NIV. Of the 63 patients (47.01%) who died, 22 (66.66%) were from the IV group and 40 (92.02%) were from the NIV-followed-by-intubation group, and 1 (1.72%) were from the NIV-only group. Multivariate analysis showed that the presence of a respiratory comorbidity (OR=16.56, 95% CI=1.56-175.48, P=0.02) was an independent predictor of survival. Conclusions: Respiratory co-morbidity is a significant adverse predictor of survival outcome. The decision on the type of respiratory support should be made on a patient-to-patient basis.

Prenatal exposure to persistent organic pollutants (POPs) is associated with neurodevelopmental disorders. In the present study, we explored whether a human-relevant POP mixture affects the development of chicken embryo cerebellum. We used a defined mixture of 29 POPs, with chemical composition and concentrations based on blood levels in the Scandinavian population. We also evaluated exposure to a prominent compound in the mixture, perfluorooctane sulfonic acid (PFOS), alone. Embryos (n = 7–9 per exposure group) were exposed by injection directly into the allantois at embryonic day 13 (E13). Cerebella were isolated at E17 and subjected to morphological, RNA-seq and shot-gun proteomics analyses. There was a reduction in thickness of the molecular layer of cerebellar cortex in both exposure scenarios. Exposure to the POP mixture significantly affected expression of 65 of 13,800 transcripts, and 43 of 2,568 proteins, when compared to solvent control. PFOS alone affected expression of 80 of 13,859 transcripts, and 69 of 2,555 proteins. Twenty-five genes and 15 proteins were common for both exposure groups. These findings point to alterations in molecular events linked to retinoid X receptor (RXR) signalling, neuronal cell proliferation and migration, cellular stress responses including unfolded protein response, lipid metabolism, and myelination. Exposure to the POP mixture increased methionine oxidation, whereas PFOS decreased oxidation. Several of the altered genes and proteins are involved in a wide variety of neurological disorders. We conclude that POP exposure can interfere with fundamental aspects of neurodevelopment, altering molecular pathways that are associated with adverse neurocognitive and behavioural outcomes.

A 50-year-old male diabetic, hypertensive and chronic smoker presented with complex aortic, splanchnic aneurysms with impending rupture of iliac artery aneurysm, underwent coiling of celiac artery, internal iliac artery, and fenestrated/chimney endovascular aortic repair. One month later, the patient landed in an emergency due to bleeding complications of common hepatic artery and gastroduodenal artery aneurysms, which were managed successfully using endovascular techniques. The mayhem of progressive nature of the disease in the patient continued as he had left lower limb ischemia due to occlusion of the iliac artery and iliac limb of the aortic graft device as he continued to smoke. All of the above sequences of events occurred over a period of 5 years. He also developed a giant aneurysm of left anterior descending of 6.8 cm diameter, which had to be repaired by open surgical technique. The patient has been followed up for 6 years since his first presentation, and he was managed successfully from all the catastrophe of events using endovascular techniques. Giant coronary artery aneurysm with previous aneurysms at multiple sites is quite unusual and rare. Currently, there is no consensus regarding the clinical characteristics, diagnostic method, and the treatment of these cases.

Thrombotic complications have been reported widely in patients with severe coronavirus disease 2019 (COVID-19) infection. There has been an increasing trend of arterial thrombosis leading to significant morbidity and mortality. We report a case of a patient with COVID-19 related pneumonia who presented with acute limb ischemia.

Introduction: UTI has been more complicated to treat because of the appearance of the pathogen with increasing resistance to antimicrobial agents. It is useful to obtain the local sensitivity pattern in the hospital setting to guide empirical prescription. Methods: This is a prospective hospital-based study to identify the organisms causing UTI and their antibiotic susceptibility. A total of 400 urine samples were collected from the patients attending general OPD of BPKIHS, Dharan, Nepal, having the symptoms of UTI using the purposive sampling technique. We analyzed the midstream, clean catch of the urine and cultured to analyze the bacterial presence. Antibiotics susceptibility was tested using the Kirby-Bauer Disk Diffusion method. The findings were analyzed for the presence of bacteria in different age and sex groups along with their response to different antibiotics commonly used in Nepal. Results: Out of 400 culture samples, 163 (40.7%) showed bacterial growth. Escherichia coli was the most common bacteria (68.7%), followed by Klebsiella spp. (7.4%). Female urine samples showed more bacterial growth compared to males (2.79:1). UTI was common among the young population of the age group (20-29 years). Most of the isolated bacteria were sensitive to Nitrofurantoin (89.7%). Conclusion: UTI commonly occurs both in males and males of all age groups. However, females are more vulnerable to infection. Among many, E. coli is the most prevalent pathogen causing the disease, which is more susceptible to nitrofurantoin. Similarly, this antibiotic is sensitive to the majority of bacteria. Therefore, nitrofurantoin may be the first choice of drug for the population in the Eastern part of Nepal suffering from UTI. Since this study was carried out among a small sample size in one tertiary care hospital, we recommend a bigger study covering a larger population, to further validate the result.

Abstract Plants are endowed with a large pool of structurally diverse small molecules known as secondary metabolites. The present study aims to virtually screen these plant secondary metabolites (PSM) for their possible anti-SARS-CoV-2 properties targeting four proteins/ enzymes which govern viral pathogenesis. Results of molecular docking with 4,704 ligands against four target proteins, and data analysis revealed a unique pattern of structurally similar PSM interacting with the target proteins. Among the top-ranked PSM which recorded lower binding energy (BE), > 50% were triterpenoids which interacted strongly with viral spike protein—receptor binding domain, > 32% molecules which showed better interaction with the active site of human transmembrane serine protease were belongs to flavonoids and their glycosides, > 16% of flavonol glycosides and > 16% anthocyanidins recorded lower BE against active site of viral main protease and > 13% flavonol glycoside strongly interacted with active site of viral RNA-dependent RNA polymerase. The primary concern about these PSM is their bioavailability. However, several PSM recorded higher bioavailability score and found fulfilling most of the drug-likeness characters as per Lipinski's rule (Coagulin K, Kamalachalcone C, Ginkgetin, Isoginkgetin, 3,3′-Biplumbagin, Chrysophanein, Aromoline, etc.). Natural occurrence, bio-transformation, bioavailability of selected PSM and their interaction with the target site of selected proteins were discussed in detail. Present study provides a platform for researchers to explore the possible use of selected PSM to prevent/ cure the COVID-19 by subjecting them for thorough in vitro and in vivo evaluation for the capabilities to interfering with the process of viral host cell recognition, entry and replication.

Introduction: Assessment of carbon dioxide (CO2) angiography for its efficacy and limitations in lower limb angioplasties for chronic limb-threatening limb ischemia needs to be evaluated in detail, as the use of CO2 as a contrast agent has a distinct advantage over conventional iodinated contrast medium (ICM) in patients with borderline chronic kidney disease (CKD), with respect to nephrotoxicity caused by the later. Aims and Objectives: To study the quality of angiography images obtained with CO2 as a contrast agent and the efficacy of CO2 angiography in guiding lower limb angioplasties for critical limb ischemia. Design: This was a prospective, observational, comparative, cohort study. Study Period: September 2017–December 2018. Materials and Methods: Patients of critical limb ischemia with raised serum creatinine level (>1.49 mg/dL) who were not on the dialysis and undergoing endovascular revascularization were enrolled in the study. Hand injections were made using CO2 Angioset. Intraoperative evaluation of image quality obtained using CO2 was done by two vascular surgeons and compared with conventional contrast medium. Necessary therapeutic intervention was performed using CO2 angiography image if reliable image was acquired using the same. Results: A total of 100 patients were evaluated consisting of 176 arterial segments, out of which 145 segments required use of ICM and 31 segments were intervened using CO2 only as a contrast agent (19 superficial femoral artery, 6 common iliac artery, 2 pop artery, 3 external iliac artery, and 1 anterior tibial artery). Assessment of scores given by the observer 1 and observer 2 was performed by their comparison for the statistical significance using McNemar–Bowker test and was found to be statistically significant with P = 0.02. Kendall's Tau b coefficient is 0.74 (significant) and Cohen's kappa is 0.63 (significant). Good-quality images were seen in above the knee (ATK) segment in 39.3% and moderate in 57.8%. However, below the knee (BTK) segments received poor image quality score in majority, i.e., 82.6%. There was significant reduction observed in the total volume of ICM. No major adverse reaction/complication encountered during the procedures was observed, except pain being the most common and distressing complication. Conclusions: CO2 angiography is a very useful tool in the armamentarium of vascular surgeon, especially while performing angioplasties for peripheral arterial disease in borderline CKD patients, not on dialysis, because it not only reduces the amount of iodinated contrast used but also has good imaging ability in ATK vessels. It was fought with multiple issues while imaging BTK vessels, leading to reduction in its reliability and feasibility in that segment.

Aim: The study was aimed to evaluate the role of two-dimensional (2D) perfusion angiography (PA) as a predictor in wound healing outcomes in patients of critical limb ischemia. Subject and Methods: It was a pilot study conducted over a period of 16 months after taking informed consent and institutional ethical clearance. The study included 40 patients of which 8 were lost to follow-up, hence the prospective data of 32 patients was collected and analyzed. Patients were subjected to endovascular intervention and 2D perfusion software was applied to the digital subtraction angiography images and its parameters were assessed. Transcutaneous oxygen tension (TcPO2) was measured pre- and postintervention and patients were closely followed up for the time taken for wound healing. Results: The median age was 62 years ranging from 30 to 85 years. Most common comorbidity was diabetes (21/32 patients). The mean Ankle–Brachial Index in the study was 0.55 and mean TcPO2 at admission was 26.5 mm of Hg. Most common involved angiosome was percutaneous transluminal angioplasty angiosome. Fifteen patients underwent direct, 9 indirect, and remaining 8 patients underwent revascularization in both territories. The mean percent improvement in TcPO2 was higher in indirect when compared to direct revascularization but it was not statistically significant. The time taken in wound healing was significantly higher in diabetics when compared to nondiabetics with P = 0.03. Most reliable parameter in 2D PA was area under the curve (AUC) which correlated with increase in volume of tissue perfusion. Patients with >100% improvement in AUC showed significantly better wound healing rates when compared to patients with

Duplication of the inferior vena cava (IVC) with coagulation mutations in the form of factor V Leiden and MTHFR mutations represents an unusual subset of patients. We are reporting a case of a 43-year-old man who presented with left iliofemoral deep venous thrombosis diagnosed on duplex ultrasound scan. At the time of catheter-directed thrombolysis with prophylactic IVC filter placement, a duplicated IVC system was observed. After thrombolysis, a stenotic lesion in the left common iliac vein and IVC was stented. IVC filters were retrieved after 6 weeks. On thrombophilia profile testing at 3 months, he was also found to have factor V Leiden and MTHFR mutations. After 12 months of follow-up, the patient is asymptomatic with a patent iliocaval venous system and is receiving lifelong anticoagulation. Keywords: Duplicated IVC, Catheter-directed thrombolysis, Deep venous thrombosis

Background: Management of injuries sustained during cholecystectomy requires expertise and involves a patient who is troubled, usually drained of personal resources. There has been an increase in incidence with laparoscopic cholecystectomy. The standard surgical management done for major biliary injuries is Roux-en-Y Hepaticojejunostomy (R-en-Y HJ). Materials and Methods: Patients managed surgically for definitive management of biliary injuries in the form of R-en-Y HJ were included. Data were collected from prospectively maintained records and through outpatient follow-up. Demographic data, early and late surgical complications, long-term outcomes, and follow-up results were analyzed. Results: Among the 62 patients, 26 were males, with a mean age of 37.4 ± 13.5 years. A total of 24 patients presented with ongoing biliary fistula. The Strasberg–Bismuth type of injury included types E1 in 8 (13%), E2 in 31 (50%), E3 in 19 (30.6%), and E4 in four patients (6.4%). There were no postoperative mortality and morbidity in 27.4% of patients. Atrophy–hypertrophy complex was seen in four patients, vascular injury in six patients, and an internal fistulisation with duodenum in two patients. Presence of comorbidities (P = 0.05), male gender (P = 0.03), tobacco use (P = 0.04), low albumin (P = 0.016), and more proximal (E4-E1) type of injury (P = 0.008) were independent predictors of postoperative morbidity (P < 0.05). The mean duration of patient follow-up was 26.2 ± 21.1 months. Conclusion: Optimization of preoperative nutrition, avoidance of intraoperative blood transfusion, proper timing of repair, and tension-free R-en-Y HJ draining all the ducts which is done at an experienced hepatobiliary center provide the best outcome.

Background: Vascular injury in extremity is a complication of both blunt and penetrating trauma. In Indian scenario, patients generally present late to the tertiary care center with mangled extremity for treatment. The aim of the study is to assess the risk factors affecting the outcome in the management of patients with lower extremity arterial trauma. Materials and Methods: A single-center, observational study was conducted at Sir Ganga Ram Hospital, New Delhi, from January 2013 to June 2017. Sixty patients of lower extremity arterial trauma who underwent revascularization were included and followed up for 6 months. All the risk factors (mode/mechanism of injury, time since injury, compartment syndrome, mangled extremity severity score [MESS], etc.,) and limb salvage were assessed at 6 months. Statistical analysis was performed using Chi-square test and Fisher's exact test. Results: Majority of the patients presented late (6–24 h) of injury and had high mean MESS (7.85). The most common mechanism of injury was blunt trauma (83.3%), and popliteal artery (72%) was the most commonly injured artery. Limb salvage was achieved in 75% of the patients. Time since injury and MESS score affected the limb salvage significantly. On multivariate analysis, MESS score was the single independent factor which affected the limb salvage (95% confidence interval, 0.231–0.769, P = 0.005). Conclusions: MESS is the most important predictors for limb salvage. Multidisciplinary team approach with timely diagnosis and immediate repair is the key to the ultimate goal of functional limb salvage.

Introduction: Postthrombotic syndrome (PTS) occurs in 20%–60% of patients after acute deep-vein thrombosis (DVT) treated with anticoagulation alone. Residual thrombus after DVT leads to ambulatory venous hypertension which consequently causes PTS. Thus, evacuating the clot during DVT itself might prevent PTS – the “Open Vein Hypothesis.” Pharmacomechanical catheter-directed thrombolysis (PCDT) evacuates the thrombus working on this very hypothesis. PCDT is usually performed using specialized devices which are expensive and not easily available in our country. In this study, we describe a method to perform PCDT using a commonly available and inexpensive guiding catheter in an aim to prevent PTS after DVT. Aims and Objectives: This study aimed to evaluate if in acute DVT, our method of PCDT reduces the occurrence of PTS, as compared to anticoagulation alone. Design: This is a prospective, randomized, comparative, cohort study. Study Period: The study was conducted from June 2016 to May 2017 with 1-year follow-up. Materials and Methods: Patients presenting with acute DVT of

Guava (Psidium guajava L.) fruit is also known as the apple of tropics, belongs to the family of genus Psidium, and is widely cultivated in tropical zones of the world. Recently, the importance of guava fruit has increased due to its inherent nutritional content, pleasant aroma, excellent flavor, and delicious taste. It is considered an excellent source of nutrients and phytochemicals. Guava is a climacteric fruit that continues to mature or ripen even after harvest, showing an increase in the rate of respiration and metabolic activities within a short period, leading to rapid senescence or spoilage of fruit. It has limitations in terms of commercialization due to short storage life after harvest and sensitivity to diseases and chilling injury during the storage period. Many postharvest technologies such as edible packaging, modified atmosphere packaging (MAP), composite packaging, controlled atmosphere packaging (CAP), antimicrobial/antifungal packaging, and nano packaging have been used to retard the chilling injury and enhance the keeping quality of guava fruits during the storage period to control respiration rate, reduce weight loss, minimize lipid oxidation, and maintain organoleptic properties. However, these packaging technologies have varied effects on the internal and external quality attributes of guava fruits. This review, therefore, discusses the physiology, mechanism of ripening, oxidation, and ethylene production of guava fruits. The review also discusses the packaging technologies and their effect on the postharvest characteristics of guava fruits during the storage period.

Hepatobiliary surgeries are associated with severe pain, and coagulopathy. Adequate pain control is vital and difficult to achieve for these patients. Epidural analgesia is considered the routine standard technique for the management of both somatic and visceral pain from major abdominal surgeries until now. However, it is invasive, blind and carries the risk of dural or vascular puncture. Coagulopathy found in patients posted for hepatobiliary surgery further increases the concerns. We found ultrasound guided erector spinae plane block as a safe, simple yet an effective alternative to epidural analgesia for postoperative pain management of hepatobiliary surgeries. Keywords: Erector Spinae Block, Thrombocytopenia, Hepatic surgery

Background: In dialysis-dependent end-stage renal disease patients, arteriovenous access (AV access) is the chief mode of hemodialysis access. Basilic vein transposition (BVT) is an alternative in patient with failed multiple AV access. The aim of the study is to assess the outcomes of BVT at 1 year of follow-up. Materials and Methods: This prospective, nonrandomized, observational study was conducted in the Department of Vascular Surgery at Sir Ganga Ram Hospital, New Delhi. Forty consenting patients with end-stage renal failure on maintenance hemodialysis having no other options utilizing superficial veins of the upper limb for AV access formation were included. All the complications, secondary interventions and patency rates were calculated at 1 year of follow-up. Statistical analysis was performed using Chi-square test, and patency rates were assessed using Kaplan–Meier survival curve. Results: Most of the patients were in the age group of 51–70 year with the mean age of 51.98 year. The mean basilic vein diameter was 2.84 mm. Fistula thrombosis was the most common complication and was seen in 17.5% cases followed by limb edema in 13% of cases. Re-interventions (fistula thrombectomy, balloon angioplasty etc.) were performed in 27.5% of the patients. The primary patency rate and secondary patency rate at 1 year of follow-up were 77.5% and 85%, respectively. Conclusions: BVT is a feasible and suitable surgical option to provide a durable and autogenous AV access to end-stage renal disease patients requiring maintenance hemodialysis.

Intimal sarcoma is a highly aggressive and rare malignant tumor of the vascular system. We are reporting this unusual primary tumor of popliteal artery presenting as aneurysm in an infant. We report a case of an 8-month-old girl with the incidental observation of nontender and pulsatile swelling in the right popliteal fossa. An arterial duplex scan and computed tomography angiography revealed an intensely enhancing well-defined lesion (3.2 cm × 2.4 cm) of the popliteal artery suggestive of pseudoaneurysm/aneurysm. The patient underwent exploration of the popliteal artery with excision of aneurysmal sac. On histopathological examination and immunohistochemical staining, findings were suggestive of intimal sarcoma. Postoperative recovery was uneventful. At 1-year of follow-up, patient is clinically stable with no disability and any signs of recurrence or metastasis. Malignancy in peripheral arterial aneurysmal is extremely rare. More empirical evidence is yet required to make the diagnostic and therapeutic protocol to deal with this aggressive tumor of the vascular system.

Purpose: Estrogens act through interaction with 2 receptor subtypes, ER alpha (ERα) and ER beta (ERβ), in human prostate. The aim of the present study was to semiquantitatively assess the differential expression of ER subtypes in human benign prostatic hyperplasia (BPH) by use of immunocytochemistry (IHC) methods and to explore their relationship with various measures of BPH. Materials and Methods: A total of 45 patients with BPH undergoing transurethral resection of the prostate and 22 patients with bladder cancer with normal prostate undergoing surveillance cystoscopy were studied as cases and controls, respectively. Quantitative immunolabeling of ER subtypes was scored by use of a semiquantitative scale. Also, correlations were assessed between ER levels in prostate and various measures of BPH. Results: Overall, we found strong immunostaining for ERα in stroma and for ERβ in epithelium, respectively. The IHC score for ERα differed significantly between BPH patients and controls in both stroma (p≤0.001) and epithelium (p=0.008), respectively. The ERβ IHC score was also significantly higher in the epithelium of BPH patients (p=0.01). Also, we found a significant correlation between prostatic ER levels and various clinical measures of BPH. Conclusions: ERs may play an important role in the pathogenesis of BPH.

Background: Skin adnexal tumors (SAT) encompass wide spectrum of benign and malignant tumors that differentiate toward one or more adnexal structures found in normal skin. Overall incidence of SATs is low yet they can be challenging to diagnose. Aims: The aim of this study is to study the spectrum and microscopic features of SATs. Materials and Methods: It was a retrospective cross-sectional, descriptive study conducted over a period of 3 years. Formalin fixed, paraffin-embedded sections were stained with hematoxylin and eosin for histopathological analysis. Results: Out of the total 34,400 biopsies, 110 cases were diagnosed as SATs comprising 39.09% of tumors with follicular differentiation followed by tumors showing sweat gland differentiation (37.27%), and sebaceous differentiation (23.63%). The age ranged from 5 years to 85 years and male:female ratio was 1.03:1. Most of the tumors were benign (82.73%) while only 17.27% were malignant. Pilomatricoma (28.2%) was the most common benign tumor while sebaceous carcinoma (11.8%) was the most common malignant tumor. Conclusion: Architectural features are of great importance in differentiating benign tumors from malignant.

Background: The success of hemodialysis depends on a functioning vascular access. The most important factor limiting the arteriovenous fistula (AVF) growth and patency is the availability of a good caliber venous segment: Cephalic veins smaller than 2.5 mm have been reported to have increased failure rates. Unfortunately, in the Indian population, we frequently come across patients with a poor cephalic vein diameter ≤2 mm. The present study was done to evaluate if primary balloon angioplasty (PBA) of these small cephalic veins could improve the primary patency rates and maturation time of autogenous AVFs, and also to compare this technique with the standard hydrostatic dilatation technique. Materials and Methods: Sixty patients requiring arteriovenous access surgery (but having small cephalic veins (≤2 mm) were randomized into two groups of thirty patients each. All patients underwent a thorough preoperative evaluation, after which they were subjected to AVF surgery. Thirty of these patients underwent standard hydrostatic dilatation (HD) whereas the remaining thirty were offered PBA of the vein before creating the fistula. These patients were followed up for 6 months and primary patency, reintervention rates, and maturation times were recorded. Results: Immediate technical success was 100% in the PBA group, with 6-month primary patency of 93.3%, whereas HD group had 73.3% immediate success and a 6-month primary patency of 63.3%. In HD group, 36.7% patients underwent re-intervention over a follow-up of 6 months, as compared to only 6.7% in PBA group. The average maturation time for PBA group was 32.83 days, whereas in HD group, it was 52.53 days. Conclusions: PBA of very small cephalic veins (≤2 mm) is a safe and feasible procedure. The technique is associated with excellent primary patency rates and decreased maturation time, significantly decreases the need for re-intervention, and is superior to the standard hydrostatic dilatation technique. It has the potential to maximize the number of patients with autogenous AVF by including those patients who have been rejected due to small cephalic veins.

Endovascular aortic repair is becoming the standard of care for abdominal aortic aneurysm. Despite aorta being a high flow system, there is still a definite risk of endograft occlusion. Management of occluded aortic endograft is highly controversial. Successful endovascular relining in aortic endograft occlusion is a technically demanding and forthcoming secondary intervention, not been studied extensively. We are reporting a case of aortic endograft thrombosis in a morbidly obese, 64-year-old gentleman with multiple comorbidities presenting with lifestyle-limiting claudication. The patient had a history of abdominal aortic aneurysm repair with aorto-uni-iliac device and femorofemoral bypass. The patient was managed by relining of aortic endograft with graft thrombectomy and snorkeling of the left renal artery. Postoperative course was uneventful. After 1 year of follow-up, the patient is free of symptoms with patent endograft. More empirical evidence is yet required to make the standard guidelines for the management of aortic endograft occlusion.

Abstract Background Anti-malarial drug resistance continues to be a leading threat to malaria control efforts and calls for continued monitoring of waning efficacy of artemisinin-based combination therapy (ACT). Artesunate + sulfadoxine/pyrimethamine (AS + SP) is used for the treatment of uncomplicated Plasmodium falciparum malaria in India. However, resistance against AS + SP is emerged in northeastern states. Therefore, artemether–lumefantrine (AL) is the recommended first line treatment for falciparum malaria in north eastern states. This study investigates the therapeutic efficacy and safety of AL for the treatment of uncomplicated falciparum malaria in three malaria-endemic states in India. The data generated through this study will benefit the immediate implementation of second-line ACT as and when required. Methods This was a one-arm prospective evaluation of clinical and parasitological responses for uncomplicated falciparum malaria using WHO protocol. Patients diagnosed with uncomplicated mono P. falciparum infection were administered six-dose regimen of AL over 3 days and subsequent follow-up was carried out up to 28 days. Molecular markers msp-1 and msp-2 were used to differentiate recrudescence and re-infection and K13 propeller gene was amplified and sequenced covering the codon 450–680. Results A total of 402 eligible patients were enrolled in the study from all four sites. Overall, adequate clinical and parasitological response (ACPR) was 98 % without PCR correction and 99 % with PCR correction. At three study sites, ACPR rates were 100 %, while at Bastar, cure rate was 92.5 % on day 28. No early treatment failure was found. The PCR-corrected endpoint finding confirmed that one late clinical failure (LCF) and two late parasitological failures (LPF) were recrudescences. The PCR corrected cure rate was 96.5 %. The mean fever clearance time was 27.2 h ± 8.2 (24–48 h) and the mean parasite clearance time was 30.1 h ± 11.0 (24–72 h). Additionally, no adverse event was recorded. Analysis of total 186 samples revealed a mutation in the k13 gene along with non-synonymous mutation at codon M579T in three (1.6 %) samples. Conclusion AL is an efficacious drug for the treatment of uncomplicated falciparum malaria. However, regular monitoring of AL is required in view of malaria elimination initiatives, which will be largely dependent on therapeutic interventions, regular surveillance and targeted vector control.

Background: Carotid endarterectomy (CEA) using eversion technique has been used by vascular surgeons across the world. A simpler technique, modified eversion endarterectomy (MEE) is emerging as a promising option. Advantages are shorter clamping time, less neurological complications, and avoidance of prosthetic patch plasty. Selective shunting can be done whenever required. In the climate of carotid artery stenting versus CEA debate, one would consider this method to reduce the morbidity of CEA. Materials and Methods: This is a retrospective analysis of patients undergoing CEA at a single institution by four vascular surgeons over a period of 2½ years (January 2012–June 2014). Data were collected from computerized medical records and various parameters analyzed. Forty patients underwent MEE during the given period. The majority were symptomatic 34 (85%). Results: One patient (2.5%) required conversion to conventional endarterectomy with patch plasty because of the long length of the plaque. One patient (2.5%) had lateralizing transient ischemic attack (TIA) in the postoperative period. Two patients had hematoma of which one was returned to operating theater for evacuation. Seven patients underwent MEE along with coronary artery bypass grafting with uneventful recovery. Selective shunting was done for four patients (10%) who had a contralateral occlusive disease or poor back bleed from an internal carotid artery (ICA) on table. Average ICA cross-clamping time was 13 min. None of the patients had cerebrovascular accident/TIA in the follow-up period. Conclusions: MEE is a simpler and easier technique to perform with comparable results when compared with other conventional techniques. MEE, in our assumption, will be the technique of choice in the future for open CEA; however, larger studies with longer follow-up are required before final validation of this technique.

A mixed adenoneuroendocrine carcinoma is a tumor composed of both adenocarcinoma and neuroendocrine carcinoma components, with each comprising at least one-third of the lesion, as defined by the World Health Organization classification of neuroendocrine neoplasms in 2010.. A 67-years-old male was admitted to the hospital with symptoms suggesting gastric cancer. Histopathology examination from endoscopic biopsy revealed adenocarcinoma. Later partial gastrectomy specimen examination the lesion show presence of well differentiated adenocarcinoma along with neuro endocrine carcinoma.

Gastric teratoma is a very rare tumour. We reviewed the literature and found that only around 100 cases have been reported. Almost all reported cases of gastric teratoma were of mature variety. Only a few cases were of immature variety. The rarity of the disease makes the diagnosis very difficult most of the cases occurred in infants. The disease is more common in males than in females. Majority of cases have been reported to arise from the greater curvature and posterior wall of the stomach. Histopathological examination confirms the diagnosis. Treatment of choice is surgical excision with close follow up. Following surgical excision prognosis is excellent. Hence, in an infant who presents with abdominal lump gastric teratoma should be kept as one of the differential diagnosis. Here, we are reporting a case of immature teratoma.

Malignant fibrous histiocytoma (MFH) usually presents in the extremities or retroperitoneum. MFH arising from renal parenchyma or renal capsule is extremely rare, only few cases have been reported in literature and portend a poor prognosis. Renal MFH is differentiated from renal cell carcinoma, renal sarcoma, and sarcomatoid renal tumor only by histological and immunohistochemical studies. Since the therapeutic options for MFH are different, its early diagnosis is imperative. Herein, we report a case of a primary renal MFH in a 35-year-old male.

Deep hole boring using slender bars that have tuned mass dampers integrated within them make the boring process chatter vibration resistant. Dampers are usually designed using classical analytical solutions that presume the (un)damped boring bar which can be approximated by a single degree of freedom system, and the damper is placed at the free end. Since the free end is also the cutting end, analytical models may result in infeasible design solutions. To place optimally tuned dampers within boring bars, but away from the free end, this paper presents a receptance coupling approach in which the substructural receptances of the boring bar modelled as a cantilevered Euler–Bernoulli beam are combined with the substructural receptances of a damper modelled as a rigid mass integrated anywhere within the bar. The assembled and damped system response thus obtained is used to predict the chatter-free machining stability limit. Maximization of this limit is treated as the objective function to find the optimal mass, stiffness and damping of the absorber. Proposed solutions are first verified against other classical solutions for assumed placement of the absorber at the free end. Verified models then guide prototyping of a boring bar integrated with a damper placed away from its free end. Experiments demonstrate a ~100-fold improvement in chatter vibration free machining capability. The generalized methods presented herein can be easily extended to design and develop other damped and chatter-resistant tooling systems.

Renal arteriovenous fistulae (AVF) are a rare condition that can be acquired, congenital or idiopathic. Idiopathic AVF are the rarest type of renal AVF. Traditionally, renal AVF were treated with surgery, but the mainstay of treatment has shifted to an endovascular approach by coil embolization. Embolization procedures are often difficult, secondary to the ‘high flow’ of the AVF, and there is a substantial risk of distal embolization of the coils. We present the case of a 63-year-old hypertensive woman who presented with pain in the right flank, of 7 days’ duration, with no other genitourinary or gastrointestinal complaints. She had undergone hysterectomy 7 years ago. CT abdomen, and subsequently CT angiography, of her abdomen were suggestive of giant right renal AVF. We successfully embolized this idiopathic renal AVF with an Amplatzer vascular plug.

Background: Dengue is the most rapidly spreading mosquitoborne viral disease in the world. Dengue fever (DF) with its severe manifestations such as dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS) has emerged as a major public health problem of international concern. Thrombocytopenia and bleeding are common complications of dengue fever, hence besides platelet counts, there is a need to assess the role of mean platelet volume. Aims: Studying association of mean platelet volume (MPV) with severity, serology & treatment outcome to assess its prognostic utility, which can be of great help in limiting morbidity & mortality associated with dengue fever. Materials and Methods: The present study was conducted in Central Pathology Lab of SMS Medical College & Hospital, Jaipur, Rajasthan from the period of March 2013 till October 2013. Blood samples were collected from 200 patients with NS 1 Antigen positivity experiencing febrile illness, clinically consistent with dengue infection. Evaluation of platelet counts, MPV, IgM and IgG antibodies was done in all these cases. Statistical Analysis: Categorical data were presented as numbers (percent) and were compared among groups using Chi-square test. Groups compared for demographic data were presented as mean and standard deviation and were compared using student t-test, ANOVA and Post-Hoc Test, Tukey Test using SPSS, version 20 for Windows. Results: A total of 200 Dengue fever cases were studied. Out of which, 68% cases were of DF, 23% DHF & 9% DSS i.e. classical dengue fever was most common presentation. Maximum (44%) cases were in age group of 15-24 years. Fever was the presenting complaint in all cases (100%). 98% cases of dengue had thrombocytopenia. MPV showed no significant correlation with severity, serology & treatment outcome, thus excluding its role in dengue cases. Conclusion: Mean platelet volume is not important as prognostic parameter in dengue fever.

Pulmonary embolism (PE) is the most severe complication of deep venous thrombosis (DVT). There have been very few studies to assess the prevalence of PE in Asian patients. The objective of this study was to define the prevalence of PE in patients presenting with suspected lower limb DVT. Methods: This was a prospective cohort study at Sir Ganga Ram Hospital, a large multispecialty hospital in New Delhi, India. From January 2001 to July 2004, 1,552 consecutive inpatients and outpatients who presented with clinically suspected lower limb DVT were enrolled in the study. Combined ascending radionuclide venography and lung perfusion scan was performed in all patients. Patients with evidence of pulmonary perfusion defects underwent ventilation lung scan. Results: Radionuclide venography-detectable DVT was noted in 744 patients, of whom 521 (70%) had suprapopliteal DVT. Of patients with DVT, 294 (39.5%) showed a high-probability lung scan and 135 (18.1%) had an intermediate-probability lung scan. Overall, 47% of patients with a high-probability scan had no clinical manifestations suggestive of PE. Conclusion: PE occurs frequently in Indian patients with symptomatic DVT. Increasing awareness will provide us with clearer ideas about the prevalence of venous thromboembolism in Asian countries.