Sir Ganga Ram Hospital

This study evaluates the feasibility, possible utility, and efficacy of apnoeic oxygenation during tracheal resection and anastomosis as an alternative strategy to conventional ventilation techniques used in tracheal surgeries. Eight patients with tracheal stenosis were studied. All had preoperative bronchoscopic balloon dilation to facilitate intubation. During surgery, continuous oxygen at 5 L/min was delivered via an airway exchange catheter positioned above the carina during tracheal anastomosis. Gas exchange parameters were monitored, showing a rise in PaCO2 and a slight decrease in PaO2 over 15 min of apnoea, without any desaturation or hypoxic events. Cross-field ventilation was not required in any case. The technique was convenient, simple to implement, and effective in maintaining oxygenation with minimal physiological disruption during tracheal anastomosis.

Background The passage of the Transplantation of Human Organs Act in 1994 banned the unethical trade in human kidneys and recognized heart beating brain death as a form of death. This enabled liver transplantation to be performed in India. We briefly recount the history of the Act’s passage and describe, in some detail, the present status of the procedure. Methods We sent a questionnaire regarding liver transplant services via email to 400 members of the Liver Transplant Society of India requesting them to provide details on liver transplantation at their centres up to 2022. We received information on 3069 of 3920 transplants that had been performed in 2022. Results There were 183 registered centres who had performed a total of 3920 liver transplants, placing India in third position behind the USA ( n =9528) and China ( n =6053) while it performed the largest number of living donor liver transplants ( n =3183) in the world. The most common indication for liver transplantation was non-alcoholic steatohepatitis (NASH)-related cirrhosis (20%). Our teams published 2449 PubMed indexed research papers and 384 foreign trainees came from 52 countries for training in liver transplantation. The concerns were the small numbers of deceased organ donation, the dominance of the private sector (96.7%), corruption in the form of kickbacks and false declarations of relationship and gender imbalance with only 22% women recipients receiving organs from men while 68% women donated their livers to men. Conclusion Liver transplantation has saved the lives of many Indians, made a major impact on Indian healthcare overall, and increased its reputation worldwide. There are problems which we hope will be tackled by increasing societal awareness.

To present authors’ experience of chromosome microarray analysis (CMA) as the first-tier test, which contributed to accumulation and annotation of copy number variations (CNVs) and discovery of novel genetic hot spots in Indian pediatric patients. Karyotyping and CMA (4X180K Agilent) were performed in 300 patients with developmental delay, dysmorphism, autism, intellectual disability or congenital malformations. Various databases such as ClinVar, Clin Gen, OMIM, DECIPHER, etc. were used for interpretation of the results. The diagnostic yield of clinically significant findings by CMA [16.00% (48/300)] was 9.0% higher than that by karyotyping [7.0% (21/300)]. There were 2.66% (08/300) patients with variations of uncertain significance (VOUS) which were challenging to interpret. Benign variations were considered normal. CMA allows increased diagnostic yield of known and new microdeletion/duplication syndromes and molecular characterization of marker chromosomes with gene annotations. There is insufficient data published from India. Every such test done on Indian patients contributes to Indian data accumulation of pathogenic CNVs (pCNVs) and VOUS for future resolution. The benefit of CMA as a first-tier test is that it can improve the understanding towards the associated known and new genetic hot spots, thus providing a better genotype–phenotype correlation. Pre-test and post-test genetic counseling is important.

Brain abscess due to Nocardia is a rare condition, usually found in immunosuppressed patients, and previous reports have shown its occurrence mostly in the supratentorial compartment. We have analysed a case of cerebellar Nocardial abscess mimicking an ischaemic stroke with a review of the literature. A case report of a patient with a cerebellar abscess and a literature review were sourced from PubMed from 1990 to the present. We present a case of an elderly patient with chronic myeloid leukaemia (post-imatinib in remission) with nephrotic syndrome presenting with symptoms suggestive of ischaemic stroke. Brain magnetic resonance imaging showed a large loculated cystic lesion in the right cerebellar hemisphere with a mass effect. He underwent surgery, and a pus culture grew Nocardia farcinica , which was sensitive to linezolid and resistant to imipenem. Early diagnosis and appropriate therapy contributed to a successful outcome, as this was a rare case of posterior fossa abscess mimicking ischaemic stroke.

Atherosclerotic cardiovascular disease (ASCVD) remains a significant global health concern, often treated with dual antiplatelet therapy (DAPT) to prevent cardiovascular incidents. Proton-pump inhibitors (PPI) are often prescribed for prolonged periods to patients on DAPT to minimize the risk of gastrointestinal bleeding; however, there are concerns about the potential for clinically significant drug–drug interaction between them. Co-administration of a PPI might reduce the antiplatelet effect of clopidogrel, thereby increasing the risk of major adverse cardiovascular events. The metabolism of PPIs varies due to genetic polymorphisms in CYP2C19, leading to different clinical outcomes. While omeprazole and esomeprazole show significant interactions with clopidogrel, rabeprazole has a lower tendency due to its distinct metabolic pathway. Comprehending these interactions is crucial for enhancing therapeutic strategies in ASCVD management. This review delves into the complex pharmacokinetics and pharmacodynamics of PPIs and their interplay with clopidogrel, with a focus on the role of cytochrome P450 enzymes.

Background Worsening heart failure (WHF) is characterized by the progression of symptoms in patients with established HF, necessitating intensified treatment, typically with diuretics. Outpatient (OP) management of WHF offers an alternative to hospitalization, as many patients experience a gradual onset of symptoms, allowing timely intervention. However, OP WHF is often underrecognized and excluded from clinical trials, highlighting the need for structured guidance. This expert consensus aims to address this gap by providing clinical practice recommendations for OP WHF management. Methodology A panel of Indian cardiologists convened for an expert meeting moderated by a leading cardiologist. Based on clinical evidence, expert insights, and live polling, consensus recommendations were developed. Results Experts agreed that WHF is defined by symptom worsening despite standard HF therapy, decompensation in chronic HF, and an increase in oral or intravenous diuretic dose. Vericiguat was recognized as suitable for patients with reduced eGFR (<30 mL/min/1.73 m²), unlike angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker/angiotensin receptor-neprilysin inhibitor (ACEi/ARB/ARNi) and digoxin. While ACEi/ARB/ARNi doses may be reduced in WHF with worsening renal function, beta-blockers should be maintained as long as possible. OP management should prioritize early vericiguat initiation alongside rapid HF therapy optimization. About 44% of experts recommended initiating vericiguat at the first follow-up (3–7 days postdischarge), whereas 33.3% preferred it as a last-line option. Management of end-stage heart failure with advanced options like assist devices and transplants is needed with failure of drug therapy, persisting end-organ failure, and repeated hospitalization. Conclusion This consensus highlights early OP department (OPD)-based recognition of WHF, OPD-based structured HF therapy optimization, and early vericiguat initiation to improve WHF management in outpatient settings.

Introduction Balloon pulmonary valvuloplasty (BPV) is the treatment of choice for valvular pulmonary stenosis (PS) in all age groups. However, there are limited data regarding its outcomes in newborns with critical PS in the current era. We are reporting the immediate and short-term outcomes of BPV in this population. Materials and Methods The study population comprised of all neonates with critical valvular PS who underwent BPV at our center between January 2015 and December 2022. The clinical and echocardiographic data were collected retrospectively and stratified as preintervention, intervention, and follow-up. Results Twenty-four neonates with critical PS underwent BPV at a mean age of 7.0 ± 6.8 days. The median pulmonary and tricuspid valve (TV) Z-scores were − 0.49 and − 1.50, respectively. The procedure was performed through the femoral and jugular veins in 15 (62.5%) and 4 (16.7%) patients, respectively. The pulmonary valve could be crossed only through the retrograde route (patent ductus arteriosus) in 5 (20.8%) patients. The mean balloon annulus ratio was 1.02 ± 0.12. Eleven (45.8%) patients required graded balloon dilatation. The procedure was successful in 22/24 patients. There was a significant reduction in the pulmonary peak transvalvular gradient (83.9 ± 14.4 mmHg to 18.2 ± 7.6 mmHg; P < 0.05). Follow-up showed a progressive increase in Z-scores of pulmonary and tricuspid valve. Two patients who developed restenosis had dysplastic pulmonary valves. Conclusion Neonates undergoing BPV have good short-term outcomes with a low restenosis rate. In patients with small TV and severe regurgitation, crossing the pulmonary valve by retrograde approach (through ductus arteriosus) is an effective method.

Background and Objectives This study aims to address the gap in understanding the factors associated with the non-disclosure of complete information by blood donors in Lahore, Pakistan. Materials and Methods This was a cross-sectional study, conducted from February to April 2024. The study involved interviewing transfusion-transmitted infection (TTI)-positive blood donors from three large hospitals in Lahore. A validated questionnaire was used to analyse the factors associated with non-disclosure of information by these donors. Results A total of 25,155 blood donors were screened, of whom 1048 tested positive for TTIs. Among these, 218 participated in the study. The majority of them (92%) reported being unaware of their infection. Among those who were aware of their infection but still proceeded with blood donation, the primary reasons for the non-disclosure of infection status included a lack of seriousness, inadequate interviewing by blood bank staff and overcrowded interview areas. A significant proportion of TTI-positive donors reported uncertain sources of infection (47%), while others reported high-risk behaviours such as interaction with sex workers (34%) and blood transfusions at unauthorized clinics (7%). Future disclosure attitudes varied, with 22% preferring to keep their status confidential. Significant correlations were found between future non-disclosure and factors such as age, marital status, education, socio-economic status and number of blood donations. Conclusion These findings emphasize the need for targeted interventions to improve donor screening and pre-donation interview protocols. The study suggests the potential use of adequate counselling and provision of appropriate interview sites to reduce non-compliant behaviour and ensure safe blood donation practices.

Mammography, a cornerstone in detection of breast cancer, relies on standardized reporting systems such as the Breast Imaging Reporting and Data System (BI-RADS) to ensure uniform interpretation and communication of findings. Over the last few decades, mammography has undergone significant advancements. Digital mammography has essentially superseded traditional film-screen mammography, resulting in higher image quality, faster processing, and easier image storage and retrieval. Furthermore, the introduction of digital breast tomosynthesis has transformed mammographic screening by producing multiplanar reconstructed images that minimize the influence of overlapping breast tissue and enhance cancer detection rates, particularly in women with dense breasts. This chapter aims to provide an overview of the BI-RADS lexicon and its application in mammography interpretation along with a brief discussion about digital breast tomosynthesis.

Endometrial cancer is the second most diagnosed gynecologic malignancy among women worldwide. The recent understanding of molecular classification of endometrial carcinoma have become important aspect of patient directed treatment. The importance of Microsatellite Instability (MSI) has been highlighted in the molecular classification emphasizing that patients belonging to MSI subgroup differ from other subgroups for molecular abnormalities, hereditary risk factors, prognosis, and response to treatment. This study was therefore conducted to investigate the frequency of MSI in endometrial carcinomas and its association with clinicopathological parameters. Total of 109 cases were enrolled in the study over a duration of 3 years. Patients’ demographic data was recorded from requisition forms. Cases were examined in routine Hematoxylin and Eosin (HE) sections. Tumor infiltrating Lymphocytes (TIL) were assessed manually by criteria proposed by International Immunooncology Biomarkers Working Group. One representative paraffin block having sufficient number of viable tumor cells was selected for immunohistochemistry (IHC) staining for mismatch repair (MMR) proteins (MLH1, MSH2, MSH2 and MSH6). Out of toal 109 cases, 100 were endometrioid, 5 were serous carcinoma, 2 were clear cell and 2 were carcinosarcoma. Seventy-seven cases (71%) were proficient mismatch repair (pMMR) and thirty two (29.00%) cases were deficient mismatch repair (dMMR). MMR deficiency was seen only in endometrioid carcinomas. No association was seen with age, size, site, myometrial invasion, tumor grade, lympho-vascular invasion (LVI) and stage of the tumor. There was higher trend towards more frequent lymph node involvement. Strong association was seen with high TIL. MSI testing which has been used historically to identify patients with Lynch Syndrome and evaluate the severity and prognosis of MSI carcinomas now plays an important role in identifying patients who will benefit from targetable therapy. MMR study therefore recommended in all cases of endometrial carcinomas and detection of MMR proteins by IHC can indirectly reflect the status of MSI and is a reliable method of MSI detection.

The chapter titled “Suicidality in the Older Population” highlights the issue of suicide in older adults. Suicide rates in this population have been steadily increasing worldwide, making it a significant public health concern. This chapter aims to provide an overview of the risk factors, prevention strategies, and management of suicidality in the older population. The chapter discusses the various factors that increase the risk of suicide in older adults, including depression, chronic medical conditions, social isolation, and cognitive impairment. The authors highlight the importance of recognizing warning signs of suicidal behavior, such as expressing suicidal thoughts, changes in mood or behavior, and engaging in risky behaviors. Prevention strategies for suicidality in the older population include routine screening for suicide risk factors, providing support and counseling, and addressing underlying mental health issues. The authors also discuss the role of family members, caregivers, and healthcare providers in suicide prevention. The chapter further emphasizes the importance of managing suicidal behavior in older adults, including emergency interventions, psychotherapy, and medication management. The authors also discuss the challenges in managing suicidality in older adults, such as stigma associated with mental health issues, physical health concerns, and medication interactions. In conclusion, the chapter will highlight the importance of recognizing and addressing suicidality in the older population. Suicide prevention and management strategies must be tailored to the unique needs of older adults, including addressing physical and mental health concerns, social isolation, and cognitive impairment. Addressing these issues can help reduce the incidence of suicide in older adults and improve their overall well-being.

Huntingtin-interacting protein 1 (HIP1) is a multi-domain heterodimeric protein mainly involved in clathrin-mediated endocytosis and vesicle trafficking. Besides endocytosis, HIP1 regulates proliferation, metastasis, and apoptosis by interacting with different binding partners in different cell types. HIP1 is overexpressed in most cancers and some oncogenic fusion proteins of receptor tyrosine kinases with HIP1 are reported. Clinical significance of HIP1-ALK fusion is being explored in lung cancers, where HIP1 functions as a metastatic suppressor. In some cancers, such as prostate and gliomas, and Merkel cell carcinoma raised HIP1 antibodies in sera can function as prognostic markers. However, there is limited information on the molecular regulators and mechanisms mediated through HIP1 in cancers. In this review, we systematically examine the recent literature on HIP1 to examine its role in various cancer types.

Williams-Campbell syndrome (WCS) is a rare congenital disorder characterised by the absence of cartilage in sub-segmental bronchi, leading to bronchiectasis. We report a case of a late adolescence male presenting with chronic respiratory symptoms initially misdiagnosed as asthma, later confirmed to have WCS following detailed evaluation. This case highlights the importance of considering WCS in the differential diagnosis of unexplained bronchiectasis and emphasises the role of advanced imaging techniques in its diagnosis.