Vishak K. Acharya

Effectiveness of Progressive Resistance Strength Training Versus Traditional Balance Exercise in Improving Balance Among the Elderly - A Randomised Controlled Trial

INTRODUCTION Falls are important health issues among the elderly people. Most falls in elderly result from abnormal balance control mechanisms. Balance and muscle force generation are directly related, and are associated with age related muscular changes. Studies addressing fall prevention have focused on various group and individualised strength training. However, evidence on strengthening of key muscles necessary for maintaining balance and postural control is lacking. OBJECTIVES To evaluate the effectiveness of individualised progressive resistance strength training (PRT) programme in improving balance for forward limits of stability in elderly with balance impairment, compared to traditional balance exercise (TBE), and combination of both (COMBI). MATERIALS AND METHODS This randomised controlled trial included three groups; 18 subjects in each aged ≥ 65 years, from the elderly care centres of Mangalore city in Southern India (between June 2008 and December 2012). Block randomisation technique was used and allocation concealment was done using sequentially arranged sealed opaque envelopes. The TBE group received 8 component traditional balance exercise; 4 times a week for 6 months. The PRT group received resistance training for the key muscles of lower extremities, using DeLormes and Watkins protocol. The COMBI group received PRT and TBE alternately (2 days of PRT and 2 days of TBE per week). Functional reach test (FRT) was used for measurement of forward limits of stability. The data was analyzed using Statistical Package for Social Sciences (SPSS) version 15. RESULTS For functional reach, PRT group had steady progression from baseline to 6 months (p<0.001). The TBE and COMBI groups showed considerable initial improvement; beyond 3 months, moderate improvement was seen. The changes in scores of FRT were significantly better for PRT than TBE. CONCLUSION Individualised PRT intervention targeting the key muscles of lower limbs is more effective than TBE in improving forward limits of stability among non-frail elderly aged ≥65 years.

A comparison of the Acapella and a threshold inspiratory muscle trainer for sputum clearance in bronchiectasis-A pilot study.

Background: Inspiratory muscle training is used to specifically strengthen the respiratory muscles. Controversy exists regarding the use of inspiratory muscle training as a method of facilitating airways clearance. Acapella is already known to be effective in airway clearance. Objective: The objective of the study was to compare the effects of the Acapella and a threshold inspiratory muscle trainer as a method of airway clearance in subjects with bronchiectasis and to determine patient preference between the two techniques. Methods: Thirty patients (10 males, 20 females) mean age of 50.67±6.37 (mean±SD) with a history of expectoration of more than 30 ml sputum per day were recruited. The sequence of therapy was allocated by block randomization. Assessment and familiarization session was perfomed on day 1. Treatments employing the Acapella and inspiratory muscle trainer were done on days 2 and 3. Treatment order and allocation was determined by block randomization. Sputum volume was measured during and 2 hours after the treatment and patient treatment preference was recorded. Results: A statistically significant difference was found in the sputum volume expectorated after treatment with the Acapella (7.16±1.12 ml) compared with the threshold inspiratory muscle trainer (6.46±1.08 ml). Patients preferred Acapella in terms of usefulness of clearing secretions. Conclusion: The present study demonstrated increased sputum clearance following the use of the Acapella when compared to the threshold inspiratory muscle trainer. In addition, the Acapella was preferred by patients who judged that it was more useful in clearing secretions.

Clinical assessment of the autonomic nervous system in diabetes mellitus and its correlation with glycemic control.

AIM Clinical assessment of the autonomic nervous system in Diabetes mellitus (DM) and its correlation with glycemic control. STUDY DESIGN Cross sectional study of 50 adult diabetes patients. MATERIALS AND METHODS Fifty patients with DM who were on regular treatment with either insulin and/or oral hypoglycemic agents were studied. Cardiovascular autonomic neuropathy (CAN) score was calculated using the clinical test variables. RESULTS Of the 50 patients 30 had no CAN, 10 had early CAN and 10 had severe CAN. The mean of CAN score increased with duration of diabetes. The mean HbA(1C) was 7.73. The mean CAN score was higher in patients who had complication of diabetes as compared to patients without complications. The heart rate variability with respiration was found to be 15.84 ± 7.02/min. The mean valsalva ratio was 1.31 ± 0.23. The mean drop in BP on standing was 7.30 ± 7.24 mmHg. The mean 30:15 ratio was 1.06 ± 0.04. The mean rise in diastolic BP on sustained hand grip was 16.04 ± 4.11 mmHg. CONCLUSIONS The prevalence of autonomic neuropathy in DM as assessed by CAN score was 40%. The CAN score did not correlate with the duration of DM. The HbA(1C) had a significant correlation with the severity of autonomic neuropathy. Occurrence of CAN correlated with the presence of peripheral neuropathy but not with the presence of retinopathy or nephropathy. All individual tests in the battery of CAN score were significantly associated with the presence of autonomic neuropathy, except 30:15 ratio.

Nasal airflow monitoring during swallowing: Evidences for respiratory-swallowing incoordination in individuals with chronic obstructive pulmonary disease

Background: Respiratory swallowing coordination is regarded as one of the several mechanisms by which the airway is protected from aspiration during swallowing. A lack of reciprocity between respiration and swallowing has been indicated as one of the mechanisms that can lead to aspiration and pneumonia. Since chronic obstructive pulmonary disease (COPD) is a pulmonary condition, we have hypothesized that there would be deficits observed in respiratory-swallow coordination in individuals with COPD. Hence, the present study was planned to investigate the respiratory-swallow coordination in individuals with COPD. Methods: Thirty-two individuals with the diagnosis of COPD and 32 normal controls were recruited for the study. Respiratory coordination for swallowing was measured using Kay Digital Swallowing Workstation. The specific swallowing tasks were recorded for each individual which was dry swallow, thin liquid swallow, and thick liquid swallow. Results: The results revealed that there was a significant difference between individuals with COPD and normal controls indicating that swallow apnea duration is prolonged in individuals with COPD. It was also observed that expiration-inspiration is the predominant pattern, followed by expiration-expiration, inspiration-expiration, and inspiration-inspiration in individuals with COPD when compared to predominant expiration-expiration swallow in normal controls followed by expiration-inspiration, inspiration-expiration, and inspiration-inspiration. Conclusion: The results of the present study gave an insight into the pattern of respiratory-swallowing coordination in individuals with COPD.

Pleural effusion: An unusual cause and association

Filaria has a wide spectrum of presentation. We hereby present a case of Filarial pleural effusion that is a rarity in itself. Filarial lung involvement is usually in the form of tropical pulmonary eosinophilia with pulmonary infiltrates and peripheral eosinophilia, unlike our case where isolated pleural effusion of Filarial etiology was detected. Microfilaria has been isolated from Pleural fluid in very few cases, and ours was one such. Of late, there have been many incidental detections of Filarial parasites from varied anatomical sites in association with malignancy. Even in our case, we had one such unusual association.

Rare Offshoot of a Common Malady Anaemia and Tuberculosis.

Haematological manifestations are one of the rarer presentations of tuberculosis and are usually of normocytic normochromic type. An association of Autoimmune Haemolytic Anaemia (AIHA) with active pulmonary tuberculosis is an exceeding rare entity, though anaemia and tuberculosis commonly co-exist. We report a patient with sputum negative pulmonary tuberculosis with associated Coombs positive AIHA. The patient responded well to Anti- Tubercular Therapy (ATT) and low dose steroids tapered over a month.

Prevalence and Spectrum of Gastro Esophageal Reflux Disease in Bronchial Asthma.

BACKGROUND There exists a complex interplay between asthma and gastroesophageal reflux disease. Both these diseases are known to aggravate each other and amelioration of one is necessary for the control of the other. There is a paucity of studies in Indian population on this subject. AIM To evaluate the clinical features and the endoscopic findings of the upper gastrointestinal tract in patients with bronchial asthma. MATERIALS AND METHODS Study was conducted at KMC group of hospitals, Mangalore in the Department of chest medicine in association with Department of gastroenterology. Subjects included 50 cases of bronchial asthma and controls were 58 non asthmatic patients with allergic rhinitis and chronic urticaria. All patients were queried about presence or absence of symptoms of upper gastro intestinal tract disorders by gastro oesophageal reflux disease (GERD) questionnaire and all the included patients underwent upper gastro intestinal endoscopy. RESULTS The study showed that symptoms of gastroesophageal reflux were significantly more in asthmatics (52%) as compared to the controls (28%). The common presenting features of gastroesophageal reflux in asthmatics were heartburn (40%) retrosternal pain (24%), nocturnal cough (18%), dyspepsia (16%) and regurgitation (14%) and the above symptoms were significantly more common in asthmatics as compared to controls. Gastroesophageal reflux disease was found to be significantly more common in the asthmatics (58%) as compared to the control group where it was present in 32.75% of the subjects. Clinical or endoscopic evidence of any upper gastrointestinal disorder was found in 68% of the asthmatics as compared to 37.93% of the controls. This difference was found to be statistically significant. CONCLUSION The study showed that gastroesophageal reflux disease was significantly more in asthmatics as compared to the controls. Upper gastrointestinal symptoms were more common in asthmatics as against controls. Clinical or endoscopic evidence of upper gastrointestinal disorder and gastroesophageal reflux disease was found in significantly higher proportion of the asthmatics as compared to the controls. Clinically silent gastroesophageal reflux disease was however seen in both control and asthmatic groups equally with a lower prevalence.

FEV 6 as screening tool in spirometric diagnosis of obstructive airway disease

Context: The use of spirometry is currently limited to the diagnosis of obstructive airway disease for tertiary centers mainly because of the unmet need for technical expertise and funding. Use in primary care asks for a simpler and cost-effective screening tool for obstructive airway disease. Aim: To estimate the efficacy of FEV6 against the current standard of FVC in the spirometric diagnosis of obstructive airway disease. Setting and Design: The Pulmonary Function Laboratory of a tertiary care hospital in Coastal South India. It was a descriptive study. Materials and Methods: We analyzed 150 serial patients on ATS standardized spirometers. The patients were classified into normal subjects and those with airway obstruction, further categorized as mild, moderate and severe and those with mixed defect. Those with obstruction were also classified as having reversible and irreversible defects. Statistical Analysis: Data was analyzed using SPSS Software (v.11.5), statistical test ANOVA and Pearson correlation was done and P less than 0.05 considered statistically significant. Results: FVC and FEV6 showed a linear correlation in all subjects. The difference in means was statistically significant in all subjects. The sensitivity and specificity of FEV1/FEV6 in comparison to FEV1/FVC were both found to be 100%. Conclusion: FEV6 is an excellent screening tool in the diagnosis of airway obstruction but, there is a necessity for further research to confirm our findings. There is also a need for reference values in an Indian setting to find out the efficiency of this new parameter. Our sample size is relatively small and comprises of a very high proportion (70%) of subjects with airway obstruction and so our results may not be applicable for use in general population.

Level of Patient Satisfaction with Chest Physiotherapy Airway Clearance Techniques in Bronchiectasis-A Survey

Objective: There is a lack of retrievable data, on patient satisfaction with Chest Physiotherapy airway clearance techniques for individuals with Bronchiectasis in Indian population. Materials and Methods: A cross-sectional survey was conducted of 140 bronchiectasis patients. The questionnaire consisted of Section-I comprising of general questions and Section-II comprising of 21 questions related to satisfaction with chest physiotherapy techniques divided under 5 domains (efficacy, convenience, comfort, satisfaction and cost effectiveness). Results: A total of 140 subjects filled the questionnaire comprising 30.7 % males and 69.3% females of mean age 57.15 + 10.80 years. The overall patients satisfied with all airway clearance techniques were above 90%. The assertion was held that postural drainage, percussions and vibrations were effective overall by 97.9% of the subjects, being convenient and satisfactory by 95.7%, comfortable by 100% and being cost effective was held by 93.7% of the subjects. Active cycle of breathing technique being overall effective, convenient, comfortable and satisfactory was opined by 100% and cost effective by 91.3% of the subjects. Forced expiratory techniques being overall effective, convenient, comfortable and satisfactory was asserted by 100% and cost effective by 91.7% of the subjects. While mechanical devices being overall effective, convenient, comfortable was opined by 100%, satisfactory by 95.65%, and cost effective by 93.47% of the subjects. Conclusion: The findings of the study suggest a high level of patient satisfaction with Chest Physiotherapy airway clearance techniques in individuals with Bronchiectasis.

Cryptogenic Organizing Pneumonia with Sarcoidosis Overlap: An Atypical Case Study

Case Summary We present a case of a young female with subacute symptoms of cough and progressive dyspnoea. On evaluation, the patient was diagnosed as cryptogenic organizing pneumonia based on her histopathological reports. However, her significant elevation of serum angiotensin-converting enzyme (SACE) levels which drop after treatment with oral steroids, relapse, and clinical presentation pointed towards sarcoidosis as clinical diagnosis. Discussion Here, in this patient, transbronchial biopsy was suggestive of cryptogenic organizing pneumonia along with chest X-ray, and the HRCT finding was also favouring the same. But in this case, we have also seen elevated levels of serum ACE which dropped significantly to the normal level along with a complete clearance of lesions with systemic steroids, and this favours sarcoidosis. Also, the recurrence was in different areas of the lung, and lesions once again responded both clinically and radiologically to steroids with a consistent drop in serum angiotensin-converting enzyme (SACE) levels, which again is a feature common in sarcoidosis. In COP, often complete clearance of the lesions is seldom seen, even though they do respond to steroids but not as dramatically as in our case. Also, recurrence of the lesion with BOOP at different sites is uncommon as it generally progresses in the same site. Conclusion This case report suggests that sarcoidosis as a possible cause of cryptogenic organizing pneumonia is worth considering with the mixed spectrum of presentation as in our case. And to our knowledge, this type of presentation of cryptogenic organizing pneumonia with sarcoidosis as an overlap disease is very rare, and this possibility needs to be explored by more series of such cases.