Effect of Yoga as an Adjunctive Therapy on the Respiratory Function of COPD Patients with mild to Severe Grades of Severity in a Tertiary Care Centre in Kerala

Introduction: Chronic obstructive pulmonary disease(COPD) being a major public health problem, pulmonaryrehabilitation along with pharmacotherapy can give betterresults while managing COPD. Almost no studies have beendone to assess the relationship between effect of yoga as anadjunctive therapy on respiratory function in COPD patientsespecially in south India. This study was an attempt to knowthe effect of selected Yogic practices on improving respiratoryfunction.Material and methods: A total of 30 cases of mild, moderateand severe grades of COPD defined as per Global Initiative forobstructive lung disease (GOLD) guidelines were recruitedin this study. The sample size was taken as 30. All selectedsubjects were assessed for spirometric evaluation, Maximuminspiratory pressure MIP (or PImax) and Maximal expiratorypressure MEP (or PEmax). Patients were taught selected yogaexercises for 1 hour, thrice a week for one month by a certifiedyoga therapist. Thereafter, patients were asked to practice athome in the morning for two months.Statistical analysis was performed using a statistical softwarepackage SPSS version 20.0. Comparison of pre-yoga andpost-yoga assessment of respiratory function at the end of eachmonth for two months was done. Continuous variables wereexpressed as Mean±SD. Effect of yoga on selected parametersat different interval of time were assessed by paired t test.P<0.05 was taken to be statistically significant.Results: FEV1%, PEFR, FVC, FEV1/FVC, showed anincreasing trend over time from pre-yoga to 1 month and preyoga to 2 month, among which FEV1% and FEV1/FVC wasstatistically significant at p <0.05. Likewise, variables PEFRalso showed a significant increase from pre- yoga to end of2nd month (p<0.05).Conclusion: yoga practices is suggestive of improvingrespiratory function in COPD patients when used adjunctivelywith standard pharmacological treatment.

Compliance with Home-based Fortification Strategies for Delivery of Iron and Zinc: Its Effect on Haematological and Growth Markers among 6-24 months Old Children in North India.

Compliance is a key component in successful implementation of the delivery of micronutrients among children. The present study evaluates the compliance with two home-based food fortification strategies (fortified complementary food or sprinkle) for providing iron and zinc among children aged 6-24 months. A total of 292 children were randomly allocated to receive either rice-based fortified complementary food and nutrition education (Cf=101), sprinkle and nutrition education (Mp=97), or nutrition education alone as control (Ed=94). All the enrolled children were breastfed at the beginning of the study and were advised to continue breastfeeding. Biweekly information on compliance and anthropometry was collected. Complete haemogram estimation was conducted at baseline and end of the study. Compliance with the fortified complementary food was higher compared to sprinkle (Cf=81%, Mp=64% child-days). Consumption of the fortified complementary food for 6 months resulted in a significant increase in mean haemoglobin in the intervention group compared to control group (Cf 1.29±1.6 g/dL; Ed 0.23±1.3 g/dL; p<0.001). Our results showed that fortified complementary food had higher compliance than sprinkle and is a suitable delivery mechanism for iron and zinc in preschool children.

An Endodontic Mishap In Maxillary Lateral Incisor With Two Roots : A Case Report.

A 24 year old male was referred with pain and swelling in relation to a previously root canal treated maxillary left lateral incisor. Radiographic examination revealed presence of a second root which was left untreated in the previous treatment. This endodontic mishap had led to the failure of the case. During the retreatment the second canal was detected and cleaned, however considering the amount of bone loss around the second root, it was resected. This case report demonstrates the need for greater attention in treating the root canal of maxillary lateral incisors due to its anomalies, and also the need for thorough evaluation of good quality preoperative radiograph to avoid such mishaps.

Zinc Deficiency: Descriptive Epidemiology and Morbidity among Preschool Children in Peri-urban Population in Delhi, India.

Community-based data relating to factors influencing zinc deficiency among preschool children in India are inadequate. Data of a large, double-blinded, randomized, controlled zinc-supplementation trial were used for assessing the descriptive epidemiology of zinc deficiency among children aged 6-35 months (n=940). In total, 609 children were followed up for 120 days for information on morbidity. Of these children, 116 from the control group belonging to the upper and the lower 25th quartile of plasma zinc status at baseline were selected for assessing the association of zinc deficiency with prospective morbidity. At baseline, demographic, socioeconomic and dietary information was collected, and anthropometric measurements and levels of plasma zinc were assessed. At baseline, 73.3% of the children were zinc-deficient (plasma zinc <70 μg/dL), of which 33.8% had levels of plasma zinc below 60 μg/dL. A significantly higher risk of morbidity was prevalent among the subjects with lower plasma zinc compared to those with higher levels of plasma zinc.

Protective effect of Withaferin-A on tumour formation in 7,12-dimethylbenz[a]anthracene induced oral carcinogenesis in hamsters.

With an aim to investigate the protective effect of Withaferin-A on 7,12-dimethylbenz[a]anthracene (DMBA) induced oral carcinogenesis in Syrian golden hamsters, tumour incidence, tumour volume and tumour burden and status of detoxication agents, lipid peroxidation and antioxidants in DMBA administered (3 times/week for 14 weeks) hamsters were assessed. Hundred percent tumour formation in DMBA alone administered animal was observed. Oral administration of Withaferin-A (20 mg/kg body weight) to DMBA administered animals for 14 weeks completely prevented the tumour incidence, tumour volume and tumour burden. Also, Withaferin-A showed significant anti-lipid peroxidative and antioxidant properties and maintained the status of phase-I and phase-II detoxication agents during DMBA-induced oral carcinogenesis. The results thus indicate that the protective effect of Withaferin-A is probably due to its anti-lipid peroxidative and antioxidant functions as well as modulating effect on carcinogen detoxication during DMBA-induced oral carcinogenesis.

Effect of zinc added to multi-vitamin supplementation containing low-dose vitamin A on plasma retinol level in children--a double-blind randomized, controlled trial.

In a community-based double-blind randomized trial in children aged 6-35 months, both intervention and control groups received a multi-vitamin syrup containing vitamin A, while the intervention group had zinc gluconate (equivalent to 10 mg of elemental zinc) additional in the syrup. There was a significant decrease in diarrhoea and pneumonia in the intervention group. This study was undertaken to investigate if addition of zinc to vitamin A had improved plasma retinol levels, which, in turn, was responsible for the effects observed in the intervention group. In a randomly-selected subsample of 200 children--100 each from the intervention and the control group, plasma retinol levels after 120 days of supplementation were measured. There was no difference in the mean plasma retinol levels [the difference in the mean 0.46 microg/dL (95% confidence interval -1.42-2.36)] between the two groups following supplementation. No difference in plasma retinol levels was observed in the subgroups based on base-line nutritional status and plasma zinc levels. Addition of zinc to low-dose vitamin A in this study did not improve the vitamin A status of children and cannot explain morbidity effects of the intervention.

Validation of visual estimation of portion size consumed as a method for estimating food intake by young Indian children.

In this observational study, estimation of food intake was evaluated using recording of portion size consumed, instead of post-weighing, as a method. In total, 930 feeding episodes were observed among 128 children aged 12-24 months in which actual intake was available by pre- and post-weighing. For each offering and feeding episode, portion size consumed was recorded by an independent nutritionist-as none, less than half, half or more, and all. Using the pre-weighed offering, available intake was estimated by multiplying portion sizes by the estimated weight. The estimated mean intake was 510.4 kilojoules compared to actual intake of 510.7 kilojoules by weighing. Similar results were found with nestum (52.0 vs 56.2 g), bread (3.8 vs 3.7 g), puffed rice (1.7 vs 1.9 g), banana (31.3 vs 24.4 g), and milk (41.6 vs 44.2 mL). Recording portion size consumed and estimating food intake from that provides a good alternative to the time-consuming and often culturally-unacceptable method of post-weighing food each time after a feeding episode.

Protective effect of hesperidin on nicotine induced toxicity in rats.

Nicotine administration (2.5 mg/kg of body weight, sc, 5 days a week for 22 weeks) enhanced lipid peroxidative indices (thiobarbituric acid reactive substances and hydroperoxides) accompanied by a significant increase in the marker enzymes alanine transaminase, aspartate transaminase, alkaline phosphatase and lactate dehydrogenase and elevated levels of cholesterol, triglycerides, phospholipids and free fatty acids in Wistar rats. There was a significant protection by hesperidin administration at different doses (25, 50, 75, 100 and 150 mg/kg body weight) in nicotine-treated rats. However, the effect of hesperidin was more significant at 25mg/kg dose. The results suggest that hesperidin exerts the protective effects by modulating the extent of lipid peroxidation. The results are supported by histopathological observations of lung, liver and kidney.

Effect of Azadirachta indica (neem) on the growth pattern of dermatophytes.

PURPOSE: To determine the minimum inhibitory concentration (MIC) and minimum fungicidal concentration (MFC) for the extracts of the leaves and seeds of the plant Azadirachta indica against various dermatophytes. METHODS: Clinical isolates of dermatophytes(Trichophyton rubrum, Trichophyton mentagrophytes and Microsporum nanum) were treated with extracts of leaves and seeds of the plant Azadirachta indica (neem) for antifungal activity by in vitro tube dilution technique. RESULTS: The MIC of neem seed extracts was 31 microg/mL for all the dermatophytes tested. The neem seed extract at 15 microg/mL concentration (below MIC) was observed to be sufficient for distorting the growth pattern of the organisms tested. CONCLUSIONS: The changes in growth curve of the treated dermatophytes were found to be statistically significant with reference to the untreated fungi.

Cardiac myxoma with glandular elements: a histologic, histochemical, and immunohistochemical evaluation.

Epithelial differentiation in cardiac myxoma is a rare phenomenon. Out of 104 surgically excised specimens, we studied 3 cases of cardiac myxoma with glandular differentiation. All the cases had well formed glands in addition to the myxoma cells lying in a myxoid background. Detailed histochemical and immunohistochemical studies suggest that the epithelial islands in cardiac myxoma show an enteric phenotype.

Ten-year experience with the arterial switch operation.

BACKGROUND: Arterial level repair is considered the most appropriate procedure for transposition of the great arteries. This report describes our experience with the arterial switch operation over the past decade. METHODS AND RESULTS: From January 1991 to January 2001, a total of 299 patients underwent an arterial switch operation for transposition of the great arteries or double-outlet right ventricle. Group I (n=169, 56.5%) comprised patients with transposition of the great arteries in whom the ventricular septum was essentially intact. Group II patients (n=130, 43.5%) had transposition of the great arteries with an additional significant ventricular septal defect or had double-outlet right ventricle with a subpulmonic ventricular septal defect. Of the total, 245 (82%) were males and 54 (18%) were females. In group I, the ages ranged from 2 days to 18 years (median 19 days) and weight ranged from 1.7 to 68 kg (median 2.5 kg). In group II, the ages ranged from 4 days to 4 years (median 90 days) and weight ranged from 2.5 to 17 kg (median 4 kg). Fifteen percent of the patients (25/169) in group I and 30% of the patients (39/130) in group II had features of bacteriologic infection. Arterial switch operation was performed on standard lines. In group I, 141 patients (83.4%) had a primary arterial switch operation while 28 (16.6%) underwent a rapid two-stage repair. Twenty-three patients required concomitant relief of associated anatomic left ventricular outflow tract obstruction. Operative mortality was 8.8% (15/169) in group I and 33% (44/130) in group II with an overall mortality of 19% (59/299). The major causes of operative mortality included pulmonary arterial hypertensive crisis (n=21), sepsis and related complications (n=16), and left ventricular failure (n=8). Coexisting arch anomalies, longer cross-clamp time, late presentation, and preoperative bacteriologic infections were incremental risk factors. Follow-up ranged from 1 to 10 years and was 87% complete. On follow-up, 91% of the patients were asymptomatic and off all medications. There were 3 late deaths and 5 patients required reoperation. CONCLUSIONS: Excellent long-term results are obtained in operative survivors following the arterial switch operation. However. operative mortality remains a concern in our set-up.

Total anomalous pulmonary venous connection: surgical experience in Indians.

BACKGROUND: We report a retrospective analysis of the demographic. morphological and clinical profiles of patients along with results of operative repair for total anomalous pulmonary venous connection. METHODS AND RESULTS: In the last 15 years, 248 patients (168 boys, 80 girls) underwent repair for total anomalous pulmonary venous connection. Their ages ranged from I day to 24 years (median 8 months) and 145 of them were < or = 1 year of age. The patients' weight ranged from 2 to 52 kg (median 5 kg). About 70% of patients (n = 174) were less than the 50th percentile of predicted weight for age and sex. The anomalous connection was supracardiac in 134 (54%), cardiac in 80 (32.2%), infracardiac in 9 (3.6%) and mixed in 25 (10.1%) patients. Fifty (20.2%) patients had obstructed drainage and 76 patients (30.2%) had moderate or severe pulmonary arterial hypertension. Forty-five patients (18.1%) had to be operated upon on an emergency basis. All the patients were operated upon using moderately hypothermic cardiopulmonary bypass. In 114 patients, circulatory arrest was used. There were 45 (19.1%) in-hospital deaths. The major causes of early death were pulmonary arterial hypertensive crisis in 19 (7.7%) and low cardiac output syndrome in 17 (6.9%) patients. Age < or = 1 year (odds ratio 2.16; 95% confidence interval: 1.22-3.82, p=0.008), severe pulmonary arterial hypertension (odds ratio 5.86; 95% confidence interval: 2-17, p=0.001), and need for emergency surgery (odds ratio 3.65; 95% confidence interval: 1.59-8.38, p=0.002) were independent risk factors for early death. Follow-up ranged from 1 to 180 months (median 48 months). There were 4 lake deaths. Actuarial survival at 12 years was 92.6% +/- 2.8%. CONCLUSIONS: In Indian circumstances, mortality continues to be high in infants with total anomalous pulmonary venous connection. Severe pulmonary arterial hypertension appears to be the most important predictor of operative mortality. Severe malnutrition, delayed diagnosis and late referrals possibly contribute to the high mortality.

Surgical experience with dissecting and nondissecting aneurysms of the ascending aorta.

BACKGROUND: Patients who underwent replacement of the ascending aorta with a prosthetic graft for treatment of ascending aortic aneurysm and dissection between January 1992 and December 2000 were studied. METHODS AND RESULTS: Bentall's operation, using a composite aortic valve and prosthetic graft. was performed in 82 patients (70 males). Indications for the procedure included ascending aortic aneurysm (n=54 including 16 patients with Marfan's syndrome): DeBakey Type I or II aortic dissection (n=26 including 10 patients with Marfan's syndrome) and ascending aortic aneurysm with severe aortic stenosis (bicuspid aortic valve disease) (n=2). Bentall's procedure with the inclusion technique was performed in 72 patients and a Cabrol fistula created in 63 patients. In 10 other patients, coronary button transfer was done without a Cabrol fistula. There were 6 early deaths (7.3%) and 8 patients required re-exploration for excessive bleeding. Eighteen patients showed low cardiac output while the wound of 8 became infected. Postoperative arrhythmia and renal failure was seen in 26 and 6 patients, respectively. Four patients had pericardial effusion. Follow-up ranged from 1 month to 8 years. There were 8 late deaths, the causes of which include congestive heart failure (n=3). cerebral hemorrhage (n=3) and sudden cardiac death (n=2). Two patients reported back with dissection of the descending thoracic aorta and await surgery. CONCLUSIONS: Bentall's operation is a safe procedure with an acceptable mortality and morbidity.

Infective complications of central venous catheters in cardiac surgical patients.

Prospective randomised study was conducted over a 24 months period in a cardiac surgical intensive care unit to determine the incidence of infection associated with multilumen venous catheters. The influence of various factors including fever, peripheral blood culture, catheter site, catheter usage for monitoring central venous pressure and/inotrope therapy on infection rates were statistically evaluated. A total of 100 catheters submitted to the Microbiology laboratory were bacteriologically examined. Forty-nine of these were inserted into upper body sites, and 51 were inserted into the femoral vein. Twenty-one were triple-lumen catheters. Catheters were removed when a central line was no longer necessary. Catheter tips were cultured by semiquantitative technique for aerobic and anaerobic bacteria. Bacteremia occurred in 3% of catheter insertions; (Enterococcus faecalis, one; Enterobacter spp. One; Acinetobacter spp., one); and catheter colonisation developed in 24%. Neither catheter colonisation nor catheter related infection were associated with any of the risk factors evaluated. Our data indicates that central venous catheters are safe to use in our patients. The inability to identify "risk factors" for catheter infection emphasise the need to maintain a high index of suspicion.

Fatal atypical mycobacterial infection in a cardiac transplant recipient.

A 37-year-old female underwent heart transplantation for giant cell myocarditis. The patient died within three-and-a-half months of cardiac transplantation. Postmortem specimens from the heart and lung showed multiple necrotizing granulomas with numerous acid-fast bacilli. Polymerase chain reaction done on both the postmortem samples confirmed the presence of atypical mycobacterial infection. This fatal case of atypical mycobacteriosis in a cardiac transplant patient is reported for its rarity.

Does inhaled nitric oxide improve survival in operated congenital disease with severe pulmonary hypertension?

BACKGROUND: The present study aimed to assess the impact of inhaled nitric oxide on survival following correction of congenital heart defects with residual pulmonary arterial hypertension. METHODS AND RESULTS: Inhaled nitric oxide was utilized for the management of residual pulmonary hypertension in 24 children following surgical correction of their underlying heart defects. Their ages ranged from 15 days to 14 months (median 5 months). Pulmonary artery hypertension was diagnosed either by direct pulmonary artery pressure monitoring or by echocardiography. Inhaled nitric oxide was used electively in 22 patients when the ratio of the mean pulmonary arterial pressure and mean systemic arterial pressure exceeded 0.5. In the remaining 2 patients, nitric oxide was used only to manage a pulmonary hypertensive crisis. Inhaled nitric oxide was also used a second time in 2 patients who developed delayed pulmonary hypertensive crisis. Twenty-two patients showed an initial response to therapy and the pulmonary artery pressures dropped significantly. Of the patients on direct pulmonary artery pressure monitoring, a pulmonary artery to systemic artery pressure ratio below 0.3 on prolonged therapy was associated with a survival ratio of 4/6 (including 1 neurological death and one reoperation); that between 0.3 and 0.5 with a survival ratio of 3/4. Three out of four patients with sustained echocardiographic and clinical response also survived and were discharged from the hospital. All the patients who showed a lack of response to (n=2), tolerance to (n=1), or dependence on (n=6) the use of inhaled nitric oxide died. In addition, all 5 patients who had a pulmonary hypertensive crisis died, 3 in spite of successful resuscitation with nitric oxide. Thus, excluding one neurological death and one re-operation, only 9 (41%) out of 22 patients survived. CONCLUSIONS: Though inhaled nitric oxide is effective in lowering pulmonary pressure, it does not appear to improve the survival rate following repair of congenital heart disease in those with associated severe pulmonary hypertension. A randomized trial between the use and non-use of inhaled nitric oxide is warranted to determine its exact role in influencing survival in patients with residual pulmonary hypertension following surgical repair.

Cardiac arrhythmias in surgically repaired total anomalous pulmonary venous connection: a follow-up study.

Twenty-five patients with diagnosis of total anomalous pulmonary venous connection, who had undergone corrective surgery, were studied at variable time period after surgery with 24-hour ambulatory electrocardiographic monitoring (Holter) and echocardiography. The aim of this study was to record arrhythmias, if any, and to correlate occurrence of arrhythmia with adequacy of repair and other related variables. All the patients were clinically asymptomatic. Twenty-four hours ambulatory electrocardiographic monitoring of these patients showed the presence of significant arrhythmias in 21 of the 25 patients. These included supraventricular ectopics in 19 patients, ventricular ectopics in 8, atrioventricular block in 2, right bundle branch block and atrial fibrillation 1 each and atrial tachycardia in 2 patients. There was no correlation between development of arrhythmia and age at repair, type of connection, operative approach and adequacy of repair. The study indicates that cardiac arrhythmias can occur in otherwise asymptomatic patients after correction for total anomalous pulmonary venous connection. Thus, these patients require long-term follow-up, even if they are asymptomatic.

Surgical considerations of extracardiac total cavopulmonary connection.

Extracardiac total cavopulmonary connection has been proposed as a rational alternative to the lateral intra-atrial tunnel for complex congenital cyanotic heart diseases undergoing univentricular repair. In five patients, aged 4 1/2 years to 27 years, an extracardiac lateral conduit was used for total cavopulmonary connection at our Institute. Extracardiac lateral conduits were constructed in all the five patients using polytetrafluoroethylene tube grafts. One child required reoperation because of graft thrombosis and an aortic homograft was used in him on the second occasion. Aortic cross clamp was completely avoided in all including reoperation. The results showed no early or late mortality. One child developed persistent hypoxemia and progressive hepatomegaly. Reoperation on 5th post-operative day revealed graft thrombosis with technically unrestricted anastomosis which was replaced by an aortic homograft. He also required embolectomy for inferior vena cava and hepatic veins thrombosis. Post-operative follow-up (range 3 months to 14 months) revealed all patients in functional class I and in normal sinus rhythm. Doppler echocardiography, magnetic resonance imaging and angiocardiography revealed unrestricted anastomoses and unobstructed pulmonary blood flow across the conduit. The technical advantages and haemodynamic benefits of this operation are encouraging. However, the lone incidence of graft thrombosis raises concern about the routine usage of synthetic grafts in extracardiac total pulmonary connection. Other inherent weakness appears to be the lack of growth potential of the synthetic tube.

Non-myxomatous cardiac tumours: twenty-year experience.

Eighty-eight patients underwent surgery for various cardiac tumours from January 1978 to June 1998 at our Institute. Seventy-seven tumours were myxomas, 10 were non-myxomatous and one was secondary cardiac tumour. Case records of the patients with non-myxomatous primary cardiac tumours and one secondary tumour were reviewed. Six of these primary tumours were benign and four, malignant. Age of the patients ranged from 26 days to 47 years. Among patients (3 children, 8 adults) with non-myxomatous primary cardiac tumours, dyspnoea on exertion was the commonest symptom and was the cause of presentation in seven out of 11 patients. Of the eight adults, six were in New York Heart Association functional class II/III and two in class IV. Echocardiographic diagnosis was possible in all the patients. Complete excision of the tumour was possible in all benign and two of the four malignant tumours. Incomplete resection was done in the secondary tumour. Of the six benign tumours, three were rhabdomyomas and one each of fibroma, haemangioma and lipoma. The malignant tumours were one each of fibrosarcoma, angiosarcoma, unclassified sarcoma and malignant mesothelioma. The secondary tumour was a malignant thymoma. Follow-up ranged from 1 to 10 years (mean 7.2 years). Of the patients with benign tumours, four out of six are alive; one patient died on the first post-operative day and one lost to follow-up. Two of the four patients with malignant cardiac tumours died, one was lost to follow-up and one is alive two years after surgery. The patient with secondary malignant thymoma to the superior vena cava was lost to follow-up three months after an uneventful recovery from surgery.