Aster Medcity

Scrub typhus is a mite-borne rickettsial infection endemic in many parts of India and typically causes small-vessel vasculitis; large-vessel involvement is rare. We report a 52-year-old immunosuppressed man on long-term tofacitinib who presented with prolonged fever, weight loss, and systemic inflammation, and was found to have multiple pseudoaneurysms involving the abdominal aorta, carotid, and popliteal arteries, along with pulmonary nodules and necrotic lymphadenopathy. Extensive evaluation for tuberculosis, fungal infections, and bacterial endocarditis was negative, with no response to broad-spectrum antimicrobials or antitubercular therapy. Serology for scrub typhus was positive following identification of travel to an endemic area, and doxycycline led to rapid clinical and biochemical improvement. Selected pseudoaneurysms were managed surgically and endovascularly with good outcomes. This case highlights scrub typhus as a rare cause of large-vessel pseudoaneurysms in immunosuppressed patients in endemic regions.

Nasogastric tube (NGT) insertion is a common procedure, often performed blindly. We report a rare, near-fatal complication in a 44-year-old woman where an NGT traversed the internal jugular vein, superior vena cava, and perforated the right atrium into the pericardial cavity. Prompt imaging and surgical retrieval via sternotomy prevented tamponade or exsanguination. No esophageal injury was found; the likely entry point was the nasopharynx. A sealed duodenal perforation was managed conservatively. This case emphasizes the importance of verifying NGT placement before use and the role of confirmatory X-ray.

Background: Hypertension (HTN) is the primary modifiable risk factor for chronic coronary syndrome (CCS), which significantly contributes to morbidity and mortality. This study aimed to gather expert consensus from Indian cardiologists on managing HTN in patients with CCS, to optimize therapy and improve patient care. Methods: A consensus is based on Indian cardiologists’ inputs collected via an online survey. The questionnaire covered diagnostic practices, clinical patterns, and real-world treatment regimens for managing hypertensive CCS patients. Survey responses were analyzed and discussed during round table meetings. Further expert opinions were graded from Level A (strong consensus) to Level D (no consensus). Recommendations were formulated based on collective expert opinions. Results: The consensus highlights the clinical strategies for managing patients with CCS and associated comorbid conditions. The key diagnostic tools, such as ambulatory blood pressure monitoring and Holter electrocardiogram, are strongly recommended for comprehensive evaluation. Pharmacological management should prioritize the use of angiotensin II receptor blockers and beta-blockers combinations, particularly telmisartan–metoprolol fixed-dose combination (FDC) in the management of hypertensive CCS patients with type 2 diabetes mellitus or dyslipidemia. Conclusions: Indian cardiologists emphasized the importance of using, telmisartan–metoprolol FDC as a preferred drug regimen owing to their cost-effectiveness, improved efficacy, and enhanced adherence. These consensus recommendations aim to enhance therapeutic outcomes and guide future clinical practice in Indian context.

Indocyanine green (ICG) near-infrared fluorescence imaging is well established in gynecologic oncology, but its role in benign minimally invasive surgery is still limited and not standardized. Increasing cesarean section and endometriosis rates elevate the risk of urinary tract injury, highlighting the need for improved intraoperative visualization. This case series evaluates the practical use and reliability of ICG fluorescence for bladder and ureteral identification during benign robotic gynecologic procedures.Two patients undergoing robotic hysterectomy using the Da Vinci Xi Firefly system (Intuitive Surgical, Sunnyvale, California, United States) for benign indications had a history of prior cesarean deliveries. Intravesical ICG was administered to delineate the bladder. However, fluorescence was patchy and unreliable, with only partial bladder wall visualization despite adequate technique.In contrast, two patients with deep infiltrating endometriosis involving the ureter underwent cystoscopic retrograde instillation of ICG, which provided consistent and clear fluorescence-guided ureteral mapping, facilitating safe dissection and preservation. A fifth case involved a patient with symptomatic adenomyosis and an endometriotic ovarian cyst, in whom preoperative imaging also revealed an ectopic left kidney, requiring careful retroperitoneal assessment and ureteral identification during robotic hysterectomy.All surgeries were completed robotically without complications. Ureteral visualization with ICG was reproducible and effective, while bladder demarcation using intravesical ICG showed variable fluorescence, likely due to fibrosis and impaired diffusion in scarred tissue.Fluorescence-guided robotic surgery using ICG is a valuable adjunct for ureteral identification in benign gynecology, particularly in advanced endometriosis. However, its application for bladder demarcation after multiple cesarean sections appears less reliable, showing the need for protocol improvement and further evaluation before routine use.

Level IV, therapeutic study.

Autoimmune hepatitis (AIH) in children presents significant diagnostic and therapeutic challenges requiring a multidisciplinary and evidence-based approach. The Indian Society of Pediatric Gastroenterology, Hepatology, and Nutrition (ISPGHAN) convened a consensus meeting on February 23, 2025, bringing together national and international experts to address key clinical and research questions. The deliberations spanned epidemiology, clinical presentation, diagnosis including autoantibodies, immunoglobulin G (IgG), histology and diagnostic scores, therapeutic strategies, management of difficult-to-treat AIH, long-term monitoring, and special scenarios, such as seronegative AIH (SN-AIH), autoimmune sclerosing cholangitis/overlap syndromes and post-transplant complications like recurrence and de novo-AIH. Recommendations were formulated using standard GRADE system and finalized through structured consensus. These guidelines aim to standardize care, assist clinicians in decision-making, and improve outcomes in children with AIH across diverse healthcare settings.

Background: Kestenbaum number (KN) is the count of capillaries on the optic disc surface and a number <6 denotes optic atrophy (OA). Materials and Methods: This prospective cross-sectional study included 35 cases of OA who underwent a comprehensive ophthalmic examination, calculation of the KN following fundus photography, visual field analysis, and optical coherence tomography (OCT). Visual acuity was recorded as a logarithm of minimum angle of resolution (logMAR). The data were analyzed using one-way analysis of variance and Pearson correlation. Results: Sixty three eyes of 35 patients had optic atrophy. The average age of presentation was 47.37 ± 13.34 years. Primary OA was the most common morphological type of OA, and pituitary tumor was the most common cause of the same. The differences in average age, logMAR, grade of disc pallor, and KN among various types of OA were not statistically significant. There was a statistically significant negative correlation between KN and logMAR and the grade of disc pallor. Furthermore, KN correlated well with retinal nerve fiber layer thickness and ganglion cell thickness by OCT. There was no significant correlation between KN and visual field parameters. Conclusion: KN is a reliable indicator of the grade of OA. However, it does not aid in differentiating morphological types of OA.

Japanese narrow band imaging expert team (JNET) classification has a diagnostic accuracy above 90% in differentiating neoplastic from non-neoplastic colonic polyps as well as estimating the depth of invasion in colorectal cancer. However, its validation outside Japan is limited to expert centers and requires magnifying endoscopes. This study aimed at validating the JNET classification prospectively in a real-world setting in India using magnifying endoscopes with dual focus. We analyzed consecutive patients with colonic polyps detected via these endoscopes. The JNET classification was compared with histopathology, the gold standard and its diagnostic accuracy was assessed. Total 203 consecutive patients with colonic polyps underwent examination using a magnifying endoscope with dual focus. In real time, 331 polyps were identified and classified based on the JNET classification. Among them, 15 polyps could not be retrieved, leaving 316 polyps for histopathological comparison in the study. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of each JNET classification type, along with their 95% confidence intervals, are as follows. For Type-1 JNET classification, the values are 78% (69-86), 97% (94-99), 92% (84-97), 92% (87-95) and 92% (88-94), respectively. Type-2 A JNET classification has corresponding values of 92% (86-96), 84% (78-89), 82% (75-88), 93% (88-97) and 88% (84-91). For Type-2B JNET classification, the values are 45% (24-68), 97% (95-99), 56% (31-78), 96% (93-98) and 93% (90-96). Lastly, Type-3 JNET classification has values of 95% (87-99), 98% (96-100), 94% (85-98), 99% (97-100) and 98% (96-99), respectively. The JNET classification has good accuracy in characterizing colonic polyps using magnifying endoscopes with dual focus. Large-volume, multicentric data is necessary to validate the findings in our study.

The management of craniosynostosis is complex. This complexity is further complicated by the diverse phenotypes, syndromes, and functional issues that compound this. Although the objectives of craniofacial surgery are consistent, the current terminologies used to describe the clinical condition do not illustrate priorities and operational concerns. In addition, evidence suggests that specialists often adopt a narrow perspective when treating these conditions, a trend that underscores the need for a more integrated approach. We proposed a classification notion predicated on the patient's initial presentation. The etiology and current treatment status are included with the presentation, if available. Furthermore, our proposed classification categorizes and builds a taxonomy leading to mapping a system with the aim of establishing a universal language grounded in objectives that unite the diverse specialists involved . The objective of this study was to create a language system for interdisciplinary communication and represent various aspects of an institutional cohort of craniosynostoses. The authors adopted the authors' proposed taxonomy between 2015 and 2024 to develop a representation system using the institutional cohort as a prototype. The cohort representation system aimed to provide a pictorial representation that satisfied the following tenets: (1) simplistic, visually informative, and customizable. (2) Universally applicable to transfer information between systems and disciplines. (3) A visual summary of various facets. Building upon the categorization system, the authors previously established, the study introduces and applies the novel concept of mapping, detailing its development from the foundational categorization principles.