Integrating Yoga Into Undergraduate American Medical Education.

Undergraduate medical education (UGME) is the time when doctors' attitudes toward patients and their profession are formed. It is also a period of tremendous stress for future physicians, including high levels of negative stress. Such stress can be maladaptive and may sow the seeds of burnout and long-term dissatisfaction. We believe that the introduction of yoga practice in the 1st year of medical school could ameliorate the negative stressors to which undergraduate medical students are exposed. Although there are some studies in the U.S. and internationally that support the use of Yoga in UGME, they do not provide sufficient data to make a compelling case for widespread implementation of yoga programs in undergraduate curricula. We, therefore, wish to advocate for conducting a trial of the integration of yoga in the undergraduate medical curriculum to combine yoga's ancient health wisdom into the context of modern scientific medicine. Large, prospective, multicenter, and multi-method pilot projects are needed to identify how a program of yoga practice and theory could counter the UGME environment that ultimately produces depression, anxiety, and non-effective coping strategies among medical students. A curriculum for yoga for undergraduate medical students deserves serious consideration and a prominent place among efforts to improve UGME.

Animal disease surveillance: Its importance & present status in India.

Animal disease surveillance encompasses systematic collection of long-term data on disease events, risk factors and other relevant parameters followed by analyzing the same with reference to temporal and spatial characteristics to arrive at a conclusion so that necessary preventive measures can be taken. In India, the animal disease surveillance is done through National Animal Disease Reporting System, which is a web-based information technology system for disease reporting from States and Union Territories with the aim to record, monitor livestock disease situation and to initiate the preventive and curative action in a swift manner during disease emergencies. National Animal Disease Referral Expert System is a dynamic geographic information system and remote sensing-enabled expert system that captures an incidence of 13 economically important livestock diseases from all over the country and also provides livestock disease forecasting. The laboratories under State and Central governments, several research institutes under the Indian Council of Agricultural Research and veterinary colleges are involved in livestock disease diagnosis including zoonotic diseases. An integrated surveillance system is necessary for early detection of emerging/zoonotic diseases in humans. This review provides information on disease reporting and surveillance systems in animal health sector and the need for One Health approach to improve and strengthen the zoonotic disease surveillance system in India.

Expression of Recombinant Leptospiral Surface Lipoprotein-Lsa27 in E. coli and Its Evaluation for Serodiagnosis of Bovine Leptospirosis by Latex Agglutination Test.

The expressed recombinant leptospiral surface adhesion lipoprotein (Lsa27) of pathogenic Leptospira in E. coli was evaluated for the detection of Leptospira antibodies in cattle sera by latex agglutination test (LAT). The Lsa27 lacking signal peptide coding gene sequences from L. interrogans serovar Pomona was amplified (~ 660 bp) by PCR and the amplicon was cloned into pETiteN-HisKan vector. The expressed recombinant Lsa27 histidine-tagged fusion protein (rLsa27) was Ni-NTA affinity purified under denaturation followed by renaturation methods. The purified rLsa27 was characterized by SDS-PAGE and immunoblot, which confirmed the leptospiral protein with a MW of ~ 25 kDa. Further, the prepared sensitized latex beads coated with rLsa27 were evaluated as a diagnostic antigen for detection of pathogenic Leptospira antibodies by using known microscopic agglutination test (MAT) positive (n = 74) and negative (n = 62) sera for Leptospira antibodies in LAT, which revealed the relative diagnostic sensitivity of 91.89% and specificity of 87.10% against the gold standard serological test, MAT. Furthermore, on evaluation of developed rLsa27 LAT using serum samples from cattle associated with the history of abortions and reproductive disorder (n = 309), the relative sensitivity of 96.15%, and specificity of 89.11% were observed. Therefore, this rapid field test using the rLsa27 is first of its kind and it could be used as a screening test for the detection of Leptospira antibodies or it can be complemented by other diagnostics for the diagnosis /surveillance of bovine leptospirosis.

Accessing the Wrist: From Data to Tips and Tricks.

Over the past 2 decades, radial artery access has increasingly become the standard approach for coronary angiography and intervention. Compared with femoral arteries, transradial access is associated with better hemostasis. Transradial access has increased patient preference, facilitates early ambulation, and is cost-effective. An important limitation of transradial access is access site failure, and it carries a crossover rate of 3% to 7% in randomized prospective trials comparing radial with femoral artery access among experienced operators. Crossover rates for failed primary radial artery access can be reduced with ultrasonography guidance and increased familiarity with alternative access sites in the wrist.

Economic impacts of avian influenza outbreaks in Kerala, India.

This study assessed the short-run impact to poultry farmers, duck hatcheries, control costs, compensation paid to stakeholders (transfer payments) and market reactions on own and substitute product prices and backwater tourism (boat operators) due to avian influenza (AI) outbreaks in Kuttanad region of Kerala, India, during 2014. The primary data from 91 poultry farms (duck farms, broiler chicken and backyard poultry), four hatcheries and 90 backwater boat owners were collected through pre-tested schedules. The secondary data on transfer payments and expenditure incurred to control AI were collected from developmental departments and were analysed. The estimated loss (culling live birds, eggs and feed destruction) per duck farm was USD 9,181, USD 3,889 and USD 156 in case of commercial farms reared for meat, dual-purpose and backyard farms, respectively. The loss incurred by small-scale broiler and backyard poultry farms was USD 453 and USD 40, respectively. The loss incurred by large and small duck hatcheries was USD 11,963 and USD 5,790, respectively, due to culling of hatchlings, young birds and destroying eggs. The government invested USD 744,890 to contain the disease spread through massive culling, surveillance and monitoring of poultry and humans due to zoonotic nature of the disease. A sharp market reaction on own and substitute product prices and eight weeks' time lag in price recovery was observed. The consequential impact on tourism especially for the backwater boat operators amounted to a loss of USD 2,280/boat due to fall in tourist inflow. Since, control measures are post-incidence, it is necessary to adopt appropriate preventive bio-security measures at the farm level besides periodical screening of domestic birds in migratory birds' flyway locations like Kuttanad to reduce the AI burden on various stakeholders including government.

Serological evidence of West Nile virus infection in wild migratory and resident water birds in Eastern and Northern India.

To assess West Nile virus (WNV) infection in wild resident and migratory birds, we tested 3887 samples from 1784 birds belonging to 119 identified species within 30 families collected during 2008-10 from 13 states in India. The serum samples were tested for WNV antibodies initially by a competition ELISA and subsequently by a micro-plaque reduction neutralization test (Micro-PRNT), whereas tracheal and cloacal swabs were subjected to real-time RT-PCR for the detection of the WNV RNA. Twenty six birds (2.46%) out of 1058 tested showed evidence of flavivirus antibodies by ELISA. End point neutralization antibody determinations for WNV and Japanese encephalitis virus (JEV) showed that of the 22 ELISA positive sera, WNV-specific neutralizing antibodies were detected in 17 samples representing nine species of wild birds (residents: Purple swamphen, Little cormorant, Little egret, Black ibis and Spot-billed duck; residents with winter influx: Common coot and Mallard; migratory birds: Ruff and Purple heron), and two samples were positive for both WNV and JEV antibodies. The WNV-specific antibodies were most commonly detected in Mallards and Common coots. WNV genomic RNA was not detected by real-time RT-PCR. The results in this study suggest that wild resident birds are infected occasionally and wild migratory birds rarely with WNV. Additionally, our study provides evidence of WNV infection in eastern and northern India for the first time.

Clinical features, management, and prognosis of spontaneous coronary artery dissection.

BACKGROUND: Spontaneous coronary artery dissection (SCAD) is an acute coronary event of uncertain origin. Clinical features and prognosis remain insufficiently characterized. METHODS AND RESULTS: A retrospective single-center cohort study identified 87 patients with angiographically confirmed SCAD. Incidence, clinical characteristics, treatment modalities, in-hospital outcomes, and long-term risk of SCAD recurrence or major adverse cardiac events were evaluated. Mean age was 42.6 years; 82% were female. Extreme exertion at SCAD onset was more frequent in men (7 of 16 versus 2 of 71; P<0.001), and postpartum status was observed in 13 of 71 women (18%). Presentation was ST-elevation myocardial infarction in 49%. Multivessel SCAD was found in 23%. Initial conservative management (31 of 87) and coronary artery bypass grafting (7 of 87) were associated with an uncomplicated in-hospital course, whereas percutaneous coronary intervention was complicated by technical failure in 15 of 43 patients (35%) and 1 death. During a median follow-up of 47 months (interquartile range, 18-106 months), SCAD recurred in 15 patients, all female. Estimated 10-year rate of major adverse cardiac events (death, heart failure, myocardial infarction, and SCAD recurrence) was 47%. Fibromuscular dysplasia of the iliac artery was identified incidentally in 8 of 16 femoral angiograms (50%) undertaken before closure device placement and in the carotid arteries of 2 others with carotid dissection. CONCLUSIONS: SCAD affects a young, predominantly female population, frequently presenting as ST-elevation myocardial infarction. Although in-hospital mortality is low regardless of initial treatment, percutaneous coronary intervention is associated with high rates of complication. Risks of SCAD recurrence and major adverse cardiac events in the long term emphasize the need for close follow-up. Fibromuscular dysplasia is a novel association and potentially causative factor.

Bedside assessment of cardiac hemodynamics: the impact of noninvasive testing and examiner experience.

BACKGROUND: Knowledge of cardiac filling pressures is critical in the diagnosis and management of patients with dyspnea or heart failure. Echocardiography and B-natriuretic peptide (BNP) testing are commonly used to estimate these pressures, but their incremental value beyond physical examination remains unknown. METHODS: Right and left heart filling pressures were prospectively estimated as "normal" or "abnormal" by staff cardiologists and cardiovascular trainees based upon physical examination findings alone, or examination coupled with echocardiographic and BNP data in patients referred for cardiac catheterization. Net reclassification improvement was calculated to determine whether echocardiographic/BNP data had incremental value in the determination of right and left heart pressures. RESULTS: Two hundred fifteen observations were made by 9 examiners in 116 consecutive patients. Right and left heart pressures were accurately predicted from examination alone in 71% and 60% of observations, respectively. Examination-based accuracy was greater for staff cardiologists compared with trainees for right heart (82 vs 67%, P=.03) and left heart pressures (71% vs 55%, P=.03). Exposure to echocardiographic and BNP data did not enhance accuracy beyond bedside examination alone, both for left heart pressures (net reclassification improvement=-0.004; 95% confidence interval, -0.12-0.12) and right heart pressures (net reclassification improvement=0.02, 95% confidence interval, -0.09-0.13). CONCLUSIONS: Cardiac filling pressures can be estimated from physical examination with modest accuracy, which is enhanced with experience. While echocardiographic and BNP data predict cardiac filling pressures, they may not provide information of incremental value beyond examination alone. Rigorous teaching and practice of cardiac examination skills should continue to be emphasized during medical training.

Location of femoral artery access and correlation with vascular complications.

OBJECTIVES: The aim of the study was to document the frequency of optimal femoral artery access location and its correlation with vascular complications in contemporary practice. BACKGROUND: Vascular access bleeding during coronary interventions is associated with adverse outcomes. A potential strategy for reducing access-site bleeding is to achieve optimal location for the femoral access. However, there is a paucity of data on how well this goal is achieved in clinical practice using anatomical landmarks. METHODS: We retrospectively evaluated femoral angiograms of 300 patients undergoing percutaneous coronary intervention to identify the location of the access that had been performed using anatomical landmarks. Patients were divided into two groups based on the location of the arterial access: above the femoral bifurcation but below the inferior border of the inferior epigastric artery (optimal location) and those that were either above or below these landmarks (suboptimal location). Frequency of access site complications was recorded. RESULTS: The femoral artery access site was located outside the optimal location in 38 (13.0%) patients. There was no significant difference regards to baseline characteristics. Overall, access-related complications occurred in 17 (5.7%) patients. Vascular complications were significantly more frequent in patients who had a femoral artery access outside the optimal location (18% vs. 4%, P < 0.001). CONCLUSIONS: The femoral artery access site is not at the optimal location in a significant proportion of patients, and this is associated with an increased risk of vascular complications. Improving the rates of optimal arterial access by routine use of fluoroscopy or ultrasound guidance has the potential of reducing vascular complications and improving outcomes.

Transradial iliac artery intervention with dual downstream embolic protection.

We report a case of a thrombotic common iliac lesion with concern for elevated risk of downstream embolization during intervention. In this case, a transradial approach enabled the novel, simultaneous deployment of two embolic protection devices, one in the internal iliac artery and the other in the common femoral artery, for complete downstream protection during intervention. An endovascular stent, which accommodates a 0.035-inch wire lumen, was able to be delivered over both 0.014-inch protection device wires simultaneously and was successfully deployed with evidence of captured embolic material.

Complications associated with left ventricular puncture.

OBJECTIVE: To report complications in a consecutive series of patients undergoing percutaneous left ventricular apical puncture (LVAP) and sheath placement for diagnostic or interventional procedures. BACKGROUND: Percutaneous LVAP is only rarely used to provide hemodynamic data in the presence of mechanical prosthetic valves. Recently, LVAP has been used to facilitate complex interventional procedures such as paravalvular leak closures. These frequently necessitate placement of 4-6 F sheaths, rather than smaller needles. Optimal technique and outcomes are largely unknown for this uncommon procedure. METHODS: We retrospectively analyzed 32 patients undergoing LVAP with echocardiographic and fluoroscopic guidance at our institution between 2002 and 2009. These patients were referred to the cardiac catheterization laboratory for hemodynamic assessment to rule out prosthetic dysfunction and or to facilitate paravalvular leak closure. Sheaths ranged from 4 to 6 F were removed at the end of the procedure after reversing any anticoagulation. No specific closure devices were used for hemostasis. Frequency of access site complications associated with LVAP recorded. RESULTS: Apical access site related complications were higher in patients requiring LVAP for intervention than for diagnostic purposes (25% vs. 12.5%). Hemothorax was the most frequent serious complication occurring in 6 (19%) patients and frequently required intervention 5(16%). Three patients had local bleeding with no drop in hemoglobin or need for intervention. CONCLUSIONS: LVAP is associated with a significant incidence of access-related complications. There is a need for safe and reliable methods of closing percutaneous LVAP access sites.

Poly(lactide-co-glycolide) microspheres: a potent oral delivery system to elicit systemic immune response against inactivated rabies virus.

Rabies is an endemic, fatal zoonotic disease in the developing countries. Oral vaccination strategies are suitable for rabies control in developing countries. Studies were performed to investigate the suitability of poly(lactide-co-glycolide) (PLG) microspheres as an oral delivery system for beta-propiolactone inactivated concentrated rabies virus (CRV). Immune responses induced by encapsulated (PLG+CRV) and un-encapsulated inactivated rabies virus after oral and intraperitoneal route administrations were compared. The anti-rabies virus IgG antibody titer, virus neutralizing antibody (VNA) titers obtained by mouse neutralization test (MNT) and IgG2a and IgG1 titers of mice group immunized orally with PLG+CRV showed significantly (p<0.001) higher response than the group immunized orally with un-encapsulated CRV. There was no significant difference (p>0.05) between groups inoculated by intraperitoneal route. The stimulation index (SI) obtained by lymphoproliferation assay of PLG+CRV oral group also showed significantly (p<0.001) higher response than the group immunized orally with un-encapsulated CRV, suggesting that oral immunization activates Th1-mediated cellular immunity. Immunized mice of all experimental groups were challenged intracerebrally with a lethal dose of virulent rabies virus Challenge Virus Standard (CVS). The survival rates of mice immunized orally with PLG+CRV and CRV alone were 75% and 50%, respectively, whereas intraperitoneally immunized groups showed 100% protection. The overall results of humoral, cellular immune response and survival rates of mice immunized orally with PLG+CRV were significantly (p<0.001) higher than those of mice immunized orally with CRV alone. These data suggest that the PLG encapsulated inactivated rabies virus can be used for oral immunization against rabies.

Quadricuspid aortic valve associated with unruptured sinus of Valsalva aneurysm.

Quadricuspid aortic valve is a rare congenital anomaly. It may present as an isolated anomaly but is occasionally associated with aortic regurgitation. Sinus of Valsalva aneurysm (SVA) is also an infrequent congenital anomaly, typically associated with tricuspid aortic valves. There are only a few reported cases of SVA (ruptured) associated with quadricuspid aortic valves in the literature. We report the first case of the association of quadricuspid aortic valve with an unruptured SVA in an adult patient.

Role of the renin-angiotensin-aldosterone system in diastolic heart failure: potential for pharmacologic intervention.

Congestive heart failure (CHF) is a major public health problem that results in tremendous economic burden. Diastolic heart failure (DHF) forms an important subset with increasing incidence and prevalence. There are widely variable estimates of the prevalence, ranging from 13% to 74% of all CHF presentations, and this is predominantly a result of a lack of uniform criteria for establishing a diagnosis. New developments in management of DHF have lagged behind those for systolic heart failure (SHF), for which numerous new therapeutic and device strategies have been instituted. The renin-angiotensin-aldosterone system (RAAS) plays an important role in the pathophysiology of both SHF as well as DHF. The beneficial role of ACE inhibitors as well as aldosterone antagonists in SHF has been well established. Because of its unique role of the RAAS in establishing fibrosis at a molecular level, RAAS blockade provides an opportunity to expand the therapeutic options for DHF. Thus far, in patients with primary DHF only the angiotensin receptor type 1 antagonist candesartan has been reported to decrease morbidity and probably mortality. Large, ongoing randomized trials including TOPCAT (Trial of Aldosterone Antagonist Therapy in Adults with Preserved Ejection Fraction Congestive Heart) and the I-PRESERVE (Irbesartan in Heart Failure with Preserved Systolic Function) are currently underway to establish the role of aldosterone antagonists in patients with DHF.

ST-segment depression on the initial electrocardiogram in acute myocardial infarction-prognostic significance and its effect on short-term mortality: A report from the National Registry of Myocardial Infarction (NRMI-2, 3, 4).

This study analyzed 255,256 patients who had acute myocardial infarction and were enrolled in the National Registry of Myocardial Infarction 2, 3, and 4 (1994 to 2002). The objective was to determine in-hospital mortality rate among patients who had ST-segment depression on the initial electrocardiogram. Patients who had ST-segment depression had an in-hospital mortality rate (15.8%) similar to that of patients who had ST-segment elevation or left bundle branch block (15.5%). After adjusting for observed differences, ST-segment depression was associated with only a slightly lower odds ratio (0.91) of mortality compared with ST-segment elevation or left bundle branch block.