Risk factors of breast cancer and breast self-examination in early detection: systematic review of awareness among Indian women in community and health care professionals

BACKGROUND

This review aims at evaluating the awareness of risk factors for breast cancer (BC) and the knowledge of breast self-examination (BSE) among Indian women and health care professionals (HCPs).

METHODS

Literature search was conducted on multiple bibliographic databases with restrictions applied to English peer-reviewed journals.

RESULTS

We reviewed 37 published articles on this topic. The mean level of awareness for risk factors such as age at menarche (22.3%), age at menopause (27.1%) and late first pregnancy (34.6%) was low in community. The awareness was better among HCPs; however, there was still room for improvement.Knowledge of BSE varied from very poor (2%) to good (69.8%) in the community setting. The practice was similarly negligible (0%) to moderate (34.9%). Mean knowledge and practice of BSE in HCPs were 77.1 and 55.5%, respectively. A significant difference was noted in knowledge and practice of BSE between community and HCPs (P < 0.05).

CONCLUSIONS

The present review highlights the low level of awareness regarding risk factors for BC and BSE in the community as well as HCPs. Though BSE is not the ideal modality, this seems to be the best alternative for resource-limited settings.

Association of smokeless tobacco and cerebrovascular accident: a systematic review and meta-analysis of global data

BACKGROUND

The association of smokeless tobacco (SLT) with stroke has been dealt with in only a few reviews. The present meta-analysis aims to present the updated comprehensive summary risk of stroke in adult SLT users along with sub group analysis.

METHODS

A systematic literature search for articles evaluating risk of stroke in SLT users was conducted. The study characteristics and risk estimates were extracted independently by two authors (RG and SG). Random-effect model was used to estimate the summary relative risks.

RESULTS

The overall risk of stroke in SLT users was found to be significantly higher (1.17, 95% CI 1.04–1.30) compared to non-users, especially for users in Southeast Asian region. The results remained unchanged even after strict adjustment for smoking (1.18, 95% CI 1.04–1.32). SLT users had 1.34 times or 13.4% higher risk of fatal stroke, though risk of nonfatal stroke was not enhanced. Significantly higher risk of stroke was seen in users of chewing tobacco (1.35, 95% CI 1.20–1.50) in comparison to non-chewers. Gender-based analysis showed enhanced risk of fatal stroke in both male and female users. SLT-attributable fraction of fatal stroke was highest for India at 14.8%.

CONCLUSION

The significant higher risk of stroke with SLT use, even after adjustment for smoking, emphasizes the imperative need to include SLT cessation advice for control and prevention of stroke.

Evaluation of Web Portal for Improving Cancer Awareness in General Population in India

Background: With details on various cancers and recent advances in cancer prevention, a Web portal was developed to create awareness and value added education among Web-users in general population in villages, small towns and large cities of India. Aim: The Web portal aims at bringing awareness at the 3 levels of health related education program delivery success/efficacy triangle. The 1st level is cognitive learning of just being aware of cancer & basic knowledge. The 2nd level is a positive effect to be able to adopt life style changes that will lead to habit changes in diet, substance abuse and other life style habits and adherence to prescribed treatment. The 3rd level is actual behavioral change. Methods: A mixed methods study design incorporating etic-emic & qualitative research methodology and quantitative cross-sectional methods. We also used focused group discussions and in-depth interviews as part of qualitative study designs. Results: On the basis of data from the 100 participants, the Web portal was found to have improved attitudes toward accessing information related to cancer in participants. There was also an increase in the knowledge of the people, both general population and level 1 healthcare worker as compared with their previous knowledge about cancer. Also found was improvement in knowledge about the prevalent cancers, their screening procedures and general measures of prevention and treatment. Conclusion: On the basis of participants evaluated, we found that the Web portal may have a positive effect on cancer awareness of general population. Participants found the Web portal as a relevant tool to access information in the feedback. The comprehensive data which will be available after feedback from all participants, will help in understanding the nature of user´s response to Web based resources and its implications in improving lifestyle choices and promoting early screening & early detection of cancer.

Qiwam: A Potential Carcinogenic Smokeless Tobacco Product Consumed With Paan

Background: Qiwam (Kimam) is a liquid tobacco preparation consumed with paan. It is mostly consumed in southeast Asian region. Evidences suggest that it causes potentially malignant disorders (PMD), oral cancer (OC) and decreases sperm count. Qiwam was mentioned in earlier research publications, however details are not known. It is produced for self-consumption as well as for commercial purpose. Aim: To study in detail the ingredients and processing steps involved in the production of Qiwam. In addition, also study the adverse health implication of this smokeless tobacco product on humans. Methods: The information on qiwam was collected via literature search study, study tour to different geographical areas of India, where group discussions with the people involved in the production of qiwam, paan vendors and with community members of different age group were done. Results: Qiwam is prepared by the user for his/her own consumption or by industry for sale. Tobacco leaves and tobacco roots are boiled for several hours then soaked in water flavored with varied spices and additives. The resultant mixture is mashed, strained, and finally dried into a thick paste. It is consumed mostly with paan. Conclusion: Processing of qiwam is a complex and time taking process which involves various steps and components that may influence the carcinogenic property of the product. The different processing steps gives different taste and texture to the product. Qiwam increases the risk of cancer and hence needs to be banned or better avoided.

Using Social Media as an Effective Tool for Motivating Cancer Prevention

Background: Cancer is among leading cause of death (8.8 million) worldwide. Around 14.2 million new cases were recorded in 2012 and increasing each year. On the other hand there are about 2.8 billion users of different social media platforms (i.e., 37% of the world population). This tremendous power of social media can be used for disseminating effective information and communication on cancer prevention more efficiently (i.e., in less time to more people) to create awareness against the disease. Tobacco, alcohol and food industry have been using social media for aggressive advertising and marketing of their products. There is an urgent need to maximally use this medium of communication for advancing cancer prevention globally. Aim: To assess the role of social media in implementing effective health promotion strategies to advance cancer prevention. Methods: Extensive Web search has been done on the way social media (e.g., Facebook) is used for advancing public health communication and how it has been leveraged in the field of cancer prevention. Several Facebook pages and groups, YouTube channels were analyzed thoroughly. Various reports and articles on social media have been reviewed and analyzed. Results: Social media has been found very effective in terms of engaging greater number of population globally. Many Facebook pages and groups are available that provide information regarding specific cancer or provide support for cancer survivors. Several informative videos related to cancer prevention and survivors' stories are broadcast on various YouTube channels run by individuals, government, and nongovernment organizations. There have been many Instagram accounts on cancer but many of them don't provide relevant information on cancer prevention. However, genuine and relevant information are available through several Twitter handles. These social media platforms have very high penetration power. Facebook, YouTube, Instagram and Twitter have monthly reach to more than 1871, 1000, 500 and 263 million users respectively. This large number of user base can become a great source of spreading information on various aspects of cancer prevention through a comprehensive social media campaign. Conclusion: Social media platforms improve outreach and can also help carrying the relevant preventive health messages on cancer prevention, not only for the cancer patient but the public at large. Social media will help in amplifying the messages to the global mass while motivating prevention and health promotion to achieve public health objectives.

Relationship Between Smokeless Tobacco and Cervical Premalignant and Malignant Lesions Among the Patients Screened for Cervical Cancer in the Health Promotion Clinic, Noida

Background: Global Adult Tobacco Survey (GATS-2) India (2016-17), reported that 5.1 crore rural women and 1.4 crore urban women use tobacco in any form. Cervical cancer is the second most common cancer in India among women accounting for 22.86% of all cancer cases in women and 12% of all cancer cases in both men and women. One woman dies of cervical cancer every 8 minutes in India. The risk of cervical intraepithelial neoplasia (CIN) was found to be increased with the women who smoke but the association between smokeless tobacco (SLT) and areca nut have not been adequately reported in the literature; hence this study was contemplated to bridge the literature gap. Aim: To find the association between SLT use and cervical premalignant and malignant lesions among those women screened for cervical cancer at Health Promotion Clinic. Methods: Retrospective analysis was performed on the electronically maintained records of the individuals screened for cervical cancer from February 2014 - February 2018 at the Health Promotion Clinic at National Institute of Cancer Prevention and Research (NICPR), Noida. All married women above 30 years of age were eligible to be screened for cervical cancer using visual inspection with acetic acid (VIA) and Papanicolaou (PAP) test, if any abnormality was found colposcopy was done, if required biopsy was performed for confirmation. The premalignant lesions were treated with thermocoagulation or loop electrosurgical excision procedure (LEEP) and those diagnosed of malignancy were referred to a tertiary care center for further treatment. The participant's data on sociodemographic status, tobacco use and results cervical cancer screening are maintained in an online electronic data capture system. Results: Out of 6538 individuals attended the Health Promotion Clinic, for their oral, breast and cervical cancer screening from February 2014 - February 2018, 5431 (83.1%) were females and 1107 (16.9%) were males. All the females with eligible criteria were screened for cervical cancer 5431. Among which 126 (2.3%) reported with the habit of smoking, 595 (11%) reported of SLT use and 52 (1%) reported of both smoking and SLT use. The SLT users were at a higher risk [odds ratio (OR)] of developing cervical lesions compared with the non-SLT users diagnosed by the PAP test 1.02 (1.020-1.028). Conclusion: Women consuming SLT are at high risk of developing cervical premalignant and malignant lesions compared with the non-SLT users.

Unbranded Carcinogenic Products From Indian Terrain

Background: The burden of cancers caused due to tobacco-related carcinogenic products is increasing at an alarming rate in India. Unlike the western world, where cancer-causing products are mostly smoked (such as cigarettes), in India it is mostly consumed as such without combustion. Such products are produced for self-consumption or for selling in the local markets within specific geographical locations. There is very little information available in the public search engines (PubMed) about such products (i.e., dohra [mixture of areca nut, catechu, edible lime, peppermint, cardamom, and some flavoring agents], tuibur [tobacco water sipped and retained in mouth for 5-10 minutes and then spit out], kaddipudi [fine powder of tobacco plant used as such, or in processed form, as bricks and blocks made with jaggery and water], and hogesoppu [tobacco leaf used by women either as such or with betel]). Aim: To study the (i) geographical distribution, (ii) varieties, (iii) production and (iv) adverse health effects of unbranded chewable or drinkable carcinogenic products from India. Methods: The information on unbranded carcinogenic products was collected via study tour to different geographical areas of India, via group discussions or telephonic talks with community members of different age groups. Results: Dohra is found in the state of Uttar Pradesh, India. It majorly contains areca nut which contains a carcinogenic compound - arecoline known for causing histologic changes in the oral mucosa. Tuibur is found in the state of Manipur and Mizoram. Evidence suggests that it contains tobacco which is rich in N-nitroso compounds known for causing systemic tumors. Kaddipudi and hogesoppu are found in the state of Karnataka. Both of them contain tobacco. Conclusion: Dohra, Tuibur, kaddipudi and hogesoppu are unbranded cancer-causing products used at specific geographical locations in India. Since these products contain carcinogenic compounds, their use should be avoided.

Attitudes and Perceptions of Health Care Providers About the Implementation of Population Based Cancer Screening Program in India. A study From Assam

Background: India is facing noncommunicable diseases epidemic with cancer as one of the main reasons of mortality. To bring this epidemic under control and as a measure of secondary prevention, government of India has rolled out operational framework for population cancer screening. As cancer screening is a new concept for Indian health care providers, this study focuses on the attitudes and perceptions of HCP from a district in Assam. Aim: To know the attitudes and perceptions of healthcare providers in Assam about the implementation of population based cancer screening program in India. Methods: This study was a part of ongoing Indian Council of Medical Research project at Cachar district, Assam. The study was conducted at Silchar, Assam and the study participants were attendees of the master trainers' workshop which was conducted for the pilot cancer screening program rolled out in Cachar district, Assam. Self-administered questionnaires were used to collect data from the health care providers on the last day of the training. Data were gathered from 58 participants. The participants were medical officers, auxillary nurse midwives (ANM), accredited social health activists (ASHA), staff nurses, nongovernmental organization (NGO) representatives and other health care providers from public health facilities. Results: Majority of the study participants agreed with the concept of screening. Half of the study participants stated that they could conduct screening comfortably along with their other responsibilities. Lack of human resources and an overburdened human resource were the main challenges foreseen in the implementation of the program. 91% of the participants wanted GOI to implement the cancer screening program. Majority of the health personnel were in favor of primary health center (PHC) as the first preferable site of population cancer screening followed by subcenter being second on preference for screening. One-third of study participants opined that screening should be done by specialist doctors. Almost one fifth of participants stated that ASHA should do the screening and almost same number of participants thought that medical officer at PHC should do the screening. Conclusion: This is the first pilot study on the population based cancer screening guidelines released by the government of India. The organized screening program is yet to be rolled out in the country. Though many challenges were foreseen by the healthcare providers in carrying out the population based cancer screening, majority were optimistic for the implementation of this screening program.

Development of Operational Framework for Management of Common Cancers in India

Background and context: Cancers of the breast, uterine cervix, and oral cavity are the 3 most common malignancies in India. Overall, they comprise around one third of >1 million cases diagnosed with cancer in India each year. An effective operational framework (OF) for early detection and screening programs should play a key role in reducing and managing the cancer burden in India. Aim: i. To provide guidelines to the clinicians, and public health practitioners for screening and early detection of breast, uterine cervix, and lip or oral cavity cancers in India. ii. To build guide/roadmap for policymakers involved in developing and implementing strategies for cancer control in India. Strategy/Tactics: In collaboration with the Center for Global Health at the U.S. National Cancer Institute, 25 scientific experts comprising researchers, public health leaders, medical and dental professionals from France, India, United States, and Zambia met at Indian Council of Medical Research (ICMR)-National Institute of Cancer Prevention and Research, to summarize the feasible options and relevant evidence for screening and early detection of common cancers in India. They came out with the operational framework Program/Policy process: Recognizing the key role that effective early detection and screening programs could have in reducing the cancer burden, the ICMR-National Institute of Cancer Prevention and Research, in collaboration with the U.S. National Cancer Institute Center for Global Health, held a workshop to summarize feasible options and relevant evidence for screening and early detection of common cancers in India. Outcomes: a. A publication in Lancet: Rajaraman P, Anderson BO, Basu P, et al: Recommendations for screening and early detection of common cancers in India. Lancet Oncol 16(7):e352-e361, 2015. b. State and PHC level trainings on operational framework started in each state for the primary health care providers. What was learned: The OF acts as a guide for policymakers, clinicians, and public health practitioners who are developing and implementing strategies in cancer control. Common and consistent OF will go a long way to chart out the intensity of the problem and to rectify it.

Biochemical Profiling of Smokeless Tobacco Product Kiwam at Different Processing Steps

Introduction: Kiwam (qiwam) is a partially fermented tobacco product consumed with betel quid (paan). The major constituents of this product are tobacco, saffron (zaffrani) and some other additives. It contains tobacco-specific nitrosamines (TSNA) which is considered as a cancer causing agent. To elucidate the carcinogenic property of kiwam, biochemical profiling of its constituents at different stages of processing is needed. The major processing steps involved in the formation of kiwam and biochemical profiling/changes at each processing step is still unknown. Aim: To describe the major processing steps and biochemical changes that occur at each processing step during the preparation of kiwam. Methods: Tobacco leaves and stems were washed with Millipore water so as to remove the dirt particles from the leaves and stems. It is then boiled in water followed by filtering of the constituents to remove the leaves and stem residues. The filtrate was again boiled to form a thick paste residue. The resultant paste was partially fermented through sun curing, and lastly, saffron along with specific additives was added. The samples from each step were analyzed for biochemical profiling through Continuous Flow Autoanalyzer using Flow View Solution 3700 Analyzer (version 1.2.2) software. Results: The biochemical changes at TSNA levels were observed at each processing steps. The detailed chemical profiling will be presented during the meeting. Conclusion: Kiwam is rich in TSNA and hence its use should be avoided.

Prevalence of Gul Use, Its Predictors and Association With Oral Potentially Malignant Disorders and Oral Cancer Development in the Users of Noida, India: A Cross-Sectional Study

Background: Oral cancer is the third most common cancer in India which is attributed to the high tobacco burden especially due to a myriad of smokeless tobacco (SLT) products available in the market. Gul/Gul manjan is a commercially-produced, tobacco-based dentifrice, indigenous to rural India and Bangladesh, and mainly used by women. It is both highly addictive and carcinogenic; yet its prevalence, reasons for use and association with oral potentially malignant disorders (OPMDs) and oral cancer are scarcely documented in literature, making this study the first of its kind. Aim: To determine the prevalence of Gul use, its predictors and resultant OPMDs and oral cancer in such consumers. Methods: A cross-sectional study was performed among 3452 individuals visiting the Institute's Oral Health Promotion Clinic between December 2016-March 2018. Their basic demographic details, tobacco use history and abnormalities found on oral examination, were documented in the clinical record form. Data pertaining to Gul users was subjected to further statistical analysis. Results: Of the total individuals screened, 2.9% (n=101, P < 0.001) consumed Gul (89.1% current and 10.9% former users), with majority female consumers (86.1%) from peri-urban Noida. It was used (up to 5 times daily) mainly to alleviate dental pain due to caries/endodontic lesions, which were present in 35.6% users ( P = 0.004). A statistically significant positive association was seen between Gul use and development of OPMDs ( P < 0.001) and oral cancer ( P = 0.001), with 7.9% (n=10; 70% Gul alone users) of the overall leukoplakias/preleukoplakias (n=127), and 7.1% (n=1, Gul alone user) of all the oral cancer cases (n=14), found in Gul users. The duration of Gul use ranged up to 25 years, indicating its high dependency. Conclusion: Gul use is relatively uncommon than other SLT products in India, even among males (the major group of tobacco consumers). Apart from teeth cleaning, Gul is a cheap, easily accessible antidote for acute dental pain relief (owing to nicotine-induced analgesia) among rural women who apply it multiple times daily onto the affected teeth and adjacent gum/mucosa, often leading to its dependency. Courtesy its significant carcinogenic potential which has been clearly reported here (OPMDs and oral cancer development among users), combating/preventing its production, easy availability (in spite of the complete ban on tobacco use in dentifrices) and consumption, is essential. Therefore, the public health challenge of prevention of the use of this form of SLT ie tobacco-based dentifrices, warrants greater interest and action than that has been received thus far, which in turn would contribute to the overall mission of oral cancer prevention.

Capacity Building in Cancer Screening Using ECHO (Extension for Community Healthcare Outcomes): Innovative and Cost-Effective Model

Background and context: Three most common cancers in India are breast, uterine cervix and oral cavity, together accounting for approximately 34% of all cancers. Ministry of Health and Family Welfare, India has released an operational guidelines for cancer screening last year and has urged all the states to roll out population based cancer screening at various health care levels. As per these guidelines, the existing health care providers (HCPs) at various facilities would be rolling out the population based cancer screening in the country. However, the existing HCPs lack the skills and are not trained in cancer screening. Considering the size of the country, it is neither a feasible nor economically viable to provide in-person training for all cadres of HCPs. The limitation is comprehensively overcome by ECHO (Extension for Community Healthcare Outcomes) model provides a cost effective way to exponentially expand the capacity to mentor and train these HCPs in cancer screening best practices. ECHO as per the motto to “move knowledge rather than patients or doctors”, uses widely available one to many video-conferencing technology, didactic presentations and case based learning techniques to mentor and support HCPs to implement best practices in the field. In teleECHO clinics expert teams at an academic “hub” partner with willing participants to participate in knowledge networks in which all teach and all learn. Aim: To train the health care providers in cancer screening through technology assisted learning. Strategy/Tactics: A structured training program was designed using ECHO platform for all HCPs in separate batches that included, gynecologists, dentists and community health workers (CHWs), by virtual training to address all issues while they roll out cancer screening in their communities. Program/Policy process: A structured course of 20 week-sessions' virtual (online) cancer screening training program for various cadres of health care providers was undertaken. A typical one hour of ECHO session consisted of 25-30 minutes of didactics by the expert followed by 2 case presentations by the spokes. A “Beginner´s program” was well received by the participants who requested us to take it ahead with “Advanced training program” for specialists. Outcomes: 58 participants completed the course in cancer screening. The pre- and posttraining knowledge evaluation demonstrated a significant increase in the knowledge gained by participants. What was learned: In a resource constrained environment it is feasible to develop a basic curriculum in cancer screening program and train and support, all cadres of HCPs. Rolling out a technology enabled model such as ECHO for teaching and training can enable the development of a population based cancer screening program.

Regulatory Compliance: A Challenge for Unbranded Smokeless Tobacco Products

Background: Smokeless tobacco (SLT) is available in many forms in India and is widely used by all social groups. SLT market in India is the world largest market. Over the last 2 decades, the SLT industry in India has grown immensely, mostly in cottage industry sector and unorganized sector. Several SLT products are self-made or mixed by users themselves. This presents a great challenge for regulation of such unbranded and loose products. Cancer of the oral cavity and the pharynx are a major public health problem in India. At least 90% of these cancers are caused by SLT products use. Aim: To study the challenges for unbranded SLT products in implementing the mandated regulatory compliances under the Indian Tobacco Control Law that applies to all tobacco products. Methods: The information on unbranded/loose SLT products was collected through literature search, field trips, discussions with SLT product vendors and with community members of different age group. Results: Several types of unbranded SLT products are sold both in urban and rural India. These unbranded products vary from state to state. In some cases they vary from 1 place to another within a state. Most of the unbranded products do not comply with the legal mandates of the Indian tobacco control (COTPA) and food safety (FSSA) laws that regulate sale of tobacco products. The biggest fall-out of unbranded sale is that there is no pictorial health warnings to warn the users about the ill effects of these SLT products as required under section 7 of COTPA. In addition these products also do not mention the minimum requirement of the packaging and labeling under the legal metrology law. In absence of the pictorial health warnings these SLT products become more accessible and affordable to minors. The FSSA prohibits use of tobacco and nicotine as ingredient in any food item, however, most of the unbranded SLT products are sold with added flavorings, condiments and spices which are classified as food. Conclusion: Strict implementation of the mandated regulatory provisions is needed to check the unrestricted sale of unbranded products. Noncompliant unbranded/loose SLT products should be confiscated as per the prescriptions of the existing tobacco control and food safety laws. Findings from this paper calls for development of policies that will prevent sale of unbranded/loose SLT products in India to protect the unsuspecting youth and other vulnerable group of population from these cancer traps.

Alternate Splicing in Head and Neck Cancer: An Update

Background: Alternate splicing (AS) is a regulatory process during gene expression that allows a single gene to code multiple proteins. Sequencing of RNA (RNA-Seq) is a high throughput technology, which has been used in various studies to identify AS mechanisms in head and neck cancer (HNC). Until date, there is no available review that could update us with the major outcomes from these studies. Aim: To perform a comprehensive literature search for AS studies on HNC via RNA-Seq. Methods: A systematic literature search was performed following PRISMA guidelines to give a complete picture of AS in HNC identified through RNA-Seq. In addition, comprehensive search was also performed to identify the bioinformatics softwares that analyses RNA-Seq data for finding AS in cancer. Results: Six studies were found that used RNA-Seq data for identifying AS events in HNC. Five softwares were used by these studies to identify AS events, of which Suppa and AltAnalyze can also categorize all four AS events to subtypes, i.e., cassette exon skipping (ES), intron retention (IR), mutually exclusive exon (MXE), and alternative 5′ and 3′ splice site (ASS). Additionally, SplAdder, ASprofile, JuncBASE, and MATS softwares have been used to identify and categorize AS events in cancers other than HNC. Conclusion: Alternate splicing in HNC is a complex regulatory process of gene expression. It can be studied through RNA-Seq using various bioinformatics softwares. SplAdder, ASprofile, JuncBASE, and MATS have been used to identify and characterize other cancers, but not implemented in HNC, and hence could be used for studying AS in HNC.

Can we reduce the cardiovascular risk in peritoneal dialysis patients?

Patients with end-stage renal disease (ESRD), including those treated with peritoneal dialysis (PD), have a high risk for death, particularly from cardiovascular (CV) causes. Traditional risk factors for CV disease – like hypertension, diabetes, and dyslipidemia - are highly prevalent, often severe, and more difficult to treat in dialysis patients. Development of strategies for CV risk reduction in dialysis patients is complicated by epidemiologic studies that demonstrate paradoxical associations of some of the traditional risk factors with mortality. The difficulty is enhanced by either a paucity or negative findings of studies that have tested risk modification by targeting traditional CV risk factors. It is also clear that neither the prevalence nor the severity of traditional risk factors explains the substantial increase in risk for death associated with ESRD; this has led to identification of several nontraditional risk factors. Among these, systemic inflammation, disordered mineral metabolism, and long-term CV risk from infectious complications appear the most promising. However, the evidence in favor of the importance of these risk factors is largely limited to observational studies. In this review, we present a critical analysis of the literature to assist the clinician to reduce the CV risk of ESRD patients treated with PD.

Structural Neuroimaging in First-Episode Psychosis: a review of neuroimaging practice in an early intervention service

Introduction

The UK NICE technology guidance “Structural Neuroimaging in First-Episode Psychosis” concludes that CT/MRI is not routinely recommended as an initial investigation for first-episode psychosis.

Objectives

To evaluate the use of CT/MRI in a group of Early Intervention Service (EIS) patients with a first-episode psychosis aged 18–35 years at presentation.

Aims

To develop practice guidelines for use of neuroimaging in first-episode psychosis.

Methods

All 107 patients registered with the EIS in Hounslow, London, UK, were eligible for inclusion in this review. Data was collected from the medical records and the Picture Archiving and Communications System. Data was analysed using a microsoft excel data analysis tool. Additionally, comparisons were made between the group of patients with normal scans and that with abnormal scans. Statistical significance was determined using the chi-squared method with a significance of P < 0.05.

Results

17 patients had documented neuroimaging results. 4 scans were abnormal. There was no significant difference between the group with normal and abnormal scans in terms of gender, abnormalities of physical/neurological health, blood tests and whether the patient had any additional medical conditions. Abnormal scan results did not influence treatment or outcome for any patient.

Conclusions

The abnormal scans were not correlated to clinical indices of history, examination and laboratory tests. Abnormal scans appear to have a low yield in terms of clinical effectiveness. The findings support selective use of neuroimaging in this cohort of patients. The indications for it usage would appear to rely on clinical judgement as well clinical findings.

Tobacco control legislation in India: past and present

Beginning with the Cigarettes Act, 1975, a number of legislative strategies and programs to curb tobacco use have been implemented in India, with limited success. Currently, the Cigarettes and Other Tobacco Products Act, 2003, is designed to curb the use of tobacco in order to protect and promote public health. This review presents a critical appraisal of the current situation in its historical context.

Hypovitaminosis D, neighborhood poverty, and progression of chronic kidney disease in disadvantaged populations

In the United States, there are significant racial disparities in the incidence and prevalence of end-stage renal disease. The disparities are greatest for the Blacks and the magnitude of disparity is significantly greater than is evident from the incidence and prevalence data of end-stage renal disease - early stage chronic kidney disease is less common in Blacks and during that stage, mortality rate is significantly higher for that racial group. Recent studies have identified a genetic predisposition for non-diabetic renal disease among Blacks. However, genetic factors explain only part of the higher risk and the racial disparities are a result of a complex interplay of biology and sociology. Herein we focus on two factors and their role in explaining the higher risk for progression of chronic kidney disease among Blacks - one biologic (vitamin D deficiency) and one sociologic (neighborhood poverty). A greater Understanding of these factors is important in order to reduce the racial disparities in the United States.

Oral cytology revisited

During the last decade, oral cytology has once again become the focus of scientific research. This new interest is due to the introduction of a cytobrush for cell collection as well as a computer-assisted analysis (Oral CDx). Although promising, the sensitivity and specificity of conventional oral brush cytology remains limited. To circumvent the problems and improve the accuracy, various adjunctive analytical methods have been attempted. DNA analysis, immunocytochemical and molecular analysis are suggested methodological cytology approaches to improve the validity of oral brush cytology. An increase in sensitivity (up to 100%) and specificity (up to 100%) of oral brush biopsy has been reported on localized pre-malignant and malignant lesions. Oral brush biopsy probably will not replace histopathology in the definitive diagnosis of oral cancer, but it might be valuable for the prevention of misdiagnosis of clinically doubtful oral lesions and for the monitoring of lesions that might proceed on to oral cancer.

Low Framingham risk score despite high prevalence of metabolic syndrome in asymptomatic North-Indian population

BACKGROUND

Conflicting data exists regarding relationship between the Framingham risk score (FRS) and presence of metabolic syndrome (MS). Strong influence of age on FRS may further modify this relationship as prevalence of MS at younger age increases in South-Asian countries including India. However, only limited information is available about the prevalence of MS and its relationship with FRS in such populations at present.

METHODS

Clinical examination and biochemical investigations were performed in 1905 asymptomatic office executives who underwent routine health check-up at a tertiary care centre in India during the year 2005. Diagnosis of MS and FRS were based on the modified National Cholesterol Education Program-Adult Treatment Panel III guidelines.

RESULTS

Mean age of the subjects was 45.2 +/- 10.3 years and 71.8% were males. MS was present in 47.5% (905 of 1905) subjects. Overall, 76.8% patients with MS had 10-year cardiovascular (CV) risk < 10%, 20.6% had 10-20% risk and only 2.7% had > 20% risk according to FRS. In the lowest age-quartile, 95.9% patients had 10-year risk < 10%, 4.1% patients had 10-20% risk and none had > 20% risk. In contrast, in the highest age-quartile, less than half of the patients had 10-year risk <10% and nearly half had 10-20% risk of CV events.

CONCLUSIONS

Although the prevalence of MS is markedly high in young asymptomatic Indians, majority have low 10-year risk of CV events as estimated by FRS. These findings necessitate continued emphasis on detection of MS in these populations as reliance on FRS alone may result in underestimation of CV risk in them.

Efficacy of teriparatide in increasing bone mineral density in postmenopausal women with osteoporosis--an Indian experience

BACKGROUND AND OBJECTIVE

Osteoporosis is emerging as a leading cause of substantial morbidity in India, particularly in postmenopausal women. Teriparatide (recombinant human parathyroid hormone [1-34]) increases bone formation and improves bone microarchitecture, thereby reducing the risk of fractures. This study was conducted to evaluate the efficacy of teriparatide in increasing bone mineral density (BMD) in postmenopausal women with osteoporosis.

MATERIAL AND METHODS

A randomised, prospective, multicentre, open-label, controlled study was conducted on 82 postmenopausal women with established osteoporosis. Patients were randomly divided into control and teriparatide groups, each group consisting of 41 patients. All the patients were supplemented with 1000 mg of elemental calcium and 500 IU of vitamin D throughout the study period of 180 days. Besides, teriparatide group patients were administered teriparatide 20 microg daily subcutaneously. Lumbar spine, femoral neck and total hip BMD, bone mineral content (BMC) and bone area were measured by dual energy x-ray absorptiometry (DXA) at baseline and at the end of 6 months of treatment. Bone biomarkers, such as serum bone specific alkaline phosphatase (BSAP) and serum osteocalcin (OC), representing bone formation, and urinary deoxypyridinoline (DPD), representing bone resorption were assessed at baseline, and at 3 and 6 months of treatment.

RESULTS

During the study period, 9 patients (11%) were lost to follow-up--6 in control group (7.3%) and 3 in teriparatide group (3.7%). There was an excellent compliance to both oral and injectable medication. The investigational product teriparatide was well tolerated and there were no serious adverse events. In addition, there were no significant differences between the groups in the incidence of adverse events. The percentage of increase in lumbar spine BMD, which is the primary endpoint, was significantly (P < 0.001) higher in teriparatide group compared to that in control group (6.58% vs. 1.06%). Further, teriparatide significantly increased percentage of change in lumbar spine T-score (P < 0.001), BMC (P < 0.001) and bone area (P < 0.028) compared to control group at 6 months. Administration of teriparatide resulted in a significant percentage of increase in all the bone biomarkers in teriparatide group compared to control group patients at 3 and 6 months over baseline, thereby showing that there was a significant increase in bone turnover in teriparatide group of patients.

CONCLUSION

These results show that teriparatide is an effective and safe drug in increasing the BMD and therefore, teriparatide provides yet another new therapeutic option for reducing the risk management of osteoporosis in postmenopausal women (clinicaltrials.gov number, NCT00500409).

Detecting 3-D motion field from range image sequences

An algorithm for computing three-dimensional (3-D) velocity field and motion parameters from a range image sequence is presented. It is based on a new integral 3-D rigid motion invariant feature-the trace of a 3x3 "feature matrix" related to the moment of inertia tensor. This trace can be computed at every point of a moving surface and provides a quantitative measure of the local shape of the surface. Based on the feature's conservation along the trajectory of every moving point, a 3-D Flow Constraint Equation is formulated and solved for the velocity field. The robustness of the feature in presence of noise and discontinuity is analyzed.

Fine needle aspiration cytology of the testis as the first-line diagnostic modality in azoospermia: a comparative study of cytology and histology

OBJECTIVES

Male factors are responsible for about half of all infertility cases. Until recently, testicular biopsy was the standard method to ascertain the aetiology of azoospermia. Fine needle aspiration cytology has gained increasing popularity as a simple and minimally invasive procedure that can help in assessing testicular function accurately. This study was aimed at addressing the question whether testicular fine needle aspiration (FNA) may be used as a first-line diagnostic modality in azoospermia and to assess its usefulness in the diagnostic protocol.

METHODS

The FNA was performed in 78 consecutive azoospermic patients. To obviate sampling errors both testes were aspirated, except when contraindicated. Routine haematoxylin and eosin as well as Romanowsky staining was performed on the smears.

RESULTS

The smears were categorized on cytological examination into normal spermatogenesis in 35 (50%) patients, Sertoli cells only syndrome in 22 (31.4%) and maturation arrest at the spermatocyte/spermatid level was seen in 13 (18.4%) patients. There were eight (10.2%) cases with scant smears where cytological diagnosis could not be made. A good correlation between cytological smears and histological sections was found in 54 of 58 testes (93.1%) in which histopathological confirmation was available.

CONCLUSIONS

Testicular FNA may be utilized as a first-line investigative modality in patients with azoospermia, provided the procedure is performed and interpreted by experts.

Emerging role for fetuin-A as contributor to morbidity and mortality in chronic kidney disease

Vascular calcification (VC) is an important reason for the high burden of vascular disease among chronic dialysis patients. Chronic kidney disease (CKD) is associated with increased promoters and decreased inhibitors of VC. The circulating levels of fetuin-A, a well-described inhibitor of calcification, regulate the cell-dependent process of osteogenesis. It is not surprising that the low circulating fetuin-A levels are associated with a greater prevalence and/or severity of VC and increased risk for all-cause and cardiovascular mortality. However, high circulating fetuin-A levels appear to induce insulin resistance and, in non-dialyzed subjects with diabetic nephropathy, are directly related to VC burden. These findings underscore the need to further clarify the multiple, systemic effects of fetuin-A and its role in health and various stages of CKD.

Oral squamous cell carcinoma: etiology, pathogenesis and prognostic value of genomic alterations

Tumours of the head and neck comprise an important group of neoplasia, the incidence of which is increasing in many parts of the world. This increase remains high, despite all the advances in modern medicine. This malignancy is more prevalent in the developing world and unfortunately, has not received satisfactory attention as the more prevalent cancers of the developed world, like lung, breast, or colon cancer. Recent advances in diagnosis and therapeutic techniques of these lesions have yielded novel molecular targets, uncovered signal pathway dominance and advanced early cancer detection. This review covers recent advances in our understanding of the etiology, molecular changes and the possible role that genomic and proteomic research might play in the diagnosis and effective cure of this modern-day scourge.

Knowledge, attitude and practice of complementary and alternative medicines for diabetes

OBJECTIVES

To investigate the current status of knowledge, attitude and practice of patients with diabetes relating to complementary and alternative medicine (CAM) in an Indian community, and to determine perceptions about the use of CAM and factors influencing knowledge and usage.

SETTING

Endocrine clinic of Swaroop Rani, Nehru Hospital, Allahabad, India.

STUDY DESIGN

Hospital-based cross-sectional study.

PARTICIPANTS

Patients with diabetes attending the clinic for the first time.

SAMPLE SIZE

A sample of 493 study participants selected by systematic sampling from a population of 6094 patients with diabetes.

STUDY VARIABLES

Age, socio-economic status, educational status, religion, family history of disease, knowledge and practice of CAM, reasons for using CAM, method of use and perceived relief.

STATISTICAL ANALYSIS

Normal test of proportions, chi(2) test, Kolomogorov-Smirnov test.

RESULTS

Awareness of CAM among patients was high (71%). High prevalence of CAM use was found (67.7%) among all participants, and 95% among participants aware of CAM, mostly using 'naturopathy' (97.3% among users). No significant gap (P>0.10) between knowledge and practice in different categories was observed. Desire for quick and additional relief was the most common perceived reason for using CAM (86.8%). Higher levels of education and socio-economic status were significant positive correlates of CAM use. Knowledge of CAM was gained mainly from friends and neighbours. About 30% of users adopted CAM without allopathic treatment earlier. Only 42.2% of users perceived some relief by using CAM. Lowering of blood sugar was the most common perceived relief. CAM, along with diet control and exercise, resulted in maximum degree of satisfaction (61.9%) experienced by users. No relief was experienced by 53.6% of users of 'naturopathy'.

CONCLUSIONS AND SUGGESTIONS

Use of CAM in diabetes is highly prevalent despite high levels of disappointment after its use. In this study, we suggest the need for health education relating to CAM and self-care in diabetes. Use of CAM should be explored with patients before clinical decisions are made.

Quantitative analysis of alcohol, sugar, and tartaric Acid in alcoholic beverages using attenuated total reflectance spectroscopy

Mid-infrared (MIR) spectroscopy in attenuated total reflectance (ATR) mode was used for quantifying ethanol, sucrose, and tartaric acid in alcoholic beverages. One hundred synthetic samples were prepared with different ethanol, sucrose, and tartaric acid concentrations. Experiments were carried out on Bio-Rad 175 C FTS using an ATR accessory. Spectra were recorded in the wavelength region 600-4000 cm-1. Calibration was performed using partial least squares (PLS) algorithm. Commercially available alcoholic beverages (gin, rum, vodka, etc.) were experimented and concentration of ethanol in these samples was predicted using the developed calibration model. Chemical analysis of these commercial samples was carried out in order to compare the results. The agreement between ATR results with those of chemical analysis revealed good reliability and repeatability of the technique used.

Dissociation of clinical and laboratory diagnosis in hypothyroidism

AIMS OF THE STUDY

To assess the significance of clinical versus biochemical diagnosis of hypothyroidism using a clinical scoring index and optimize the therapeutic dose of levothyroxine in Indian patients.

METHODOLOGY

Three hundred and eighty eight cases of primary hypothyroidism (male:female ratio 1:5.8) were clinically classified as hypothyroid, euthyroid or inconclusive by Billewicz score. TSH estimation was repeated at 6-8 week intervals and appropriate adjustments in levothyroxine dosage made till the TSH was within the normal range.

RESULTS

Of 388 biochemically confirmed hypothyroid subjects less than one fourth (21.6%) could be classified as hypothyroid, almost one half were euthyroid (48.4%) and the remaining (29.9%) fell in the inconclusive category according to Billewiz score. Of 227 patients who returned for complete follow up there was a positive correlation of replacement dose with age and initial weight in females, but not in males. Baseline TSH values were not found to have a significant correlation with the initial dose. The mean replacement dose of levothyroxine (T4) in our subjects was 109.4 +/- 24.05 microg/d (range 1.25-3.84 microg/kg).

CONCLUSION

Clinical parameters alone fare poorly in establishing an unequivocal diagnosis of hypothyroidism. A biochemical confirmation is mandatory. The replacement done of T4 was found to be independent of the basal TSH level.

Management of chronic hepatitis B with New Livfit in end stage renal disease

New Livfit (NLF) is a standardized, poly-herbal formulation that has been found useful in the management of hepatitis. The aim of this placebo-controlled study was to evaluate its usefulness against hepatitis B virus in the patients of end stage renal disease (ESRD). Patients were regularly evaluated at 6, 12, 24 and 36 weeks of therapy. With 36 weeks of treatment of NLF, there was rapid clearing of HBV-DNA in a significant number of patients. Significant seroconversion of the other markers of hepatitis B and restoration of the raised levels of ALT and AST was observed. The study suggests the potential usefulness of NLF in the control of HBV infection in the patients of ESRD prior to renal transplant.

The relationship of sex hormones and cortisol with cognitive functioning in Schizophrenia

Gonadal as well as stress hormones have recently been implicated in pathophysiology and sex differences in onset, prognosis and treatment of schizophrenia. The present study investigated the effects of serum levels of oestrogen, progesterone, testosterone and cortisol on neuropsychological functioning and psychopathology in a group of 37 patients (17 women, 20 men) with schizophrenia. Neuropsychological measures included tests of attention, verbal abilities, language, memory, executive functioning, motor and speed of information processing. The results showed that oestrogen and age was associated with low positive symptom scores, and within gender, cortisol predicted poor performance on the information processing domain in men. These findings demonstrate that cortisol, in addition to the commonly reported effects of oestrogen, influences neuropsychological functioning in schizophrenia with differential effects on specific domains of cognitive functioning and underscore the need for further investigation of the modulating role of hormones on neuropsychological functioning in schizophrenia.