Spatiotemporal variations in marine macro-litter pollution along the shoreline of Koh Mun Nai, an uninhabited island in the Gulf of Thailand

Despite a recent ambitious plan to improve waste management in Thailand, few studies have monitored the impact of these policies on beached marine litter. Here, we assessed weekly the amounts and composition of stranded macro-litter (≥2.5 cm) on five beaches from an uninhabited island in Thailand during one year. A total of 24,407 items (391.86 kg) yielded a mean abundance of 3.18±11.39 items.m-2 (52.75±204.68 g.m-2), with plastic being the most abundant marine litter (48% of the total number). The overall Clean Coast Index (30.1) classified the beaches as 'extremely dirty', with a Plastic Abundance Index of 9.8 ('very high abundance' of plastics). When assessing the seasonal rates of accumulation, we found a higher flux pre-monsoon (0.05 items.m-2.d-1; 0.66 g.m-2.d-1) than post-monsoon (0.01 items.m-2.d-1; 0.35 g.m-2.d-1). Using modeling of the local hydrodynamic conditions, we explored the potential sources of the pollution, and surprisingly found that the closest river appeared not to be the source. Our results denote that the distribution and typology of marine litter were representatives of household and fishing activities, which in turn highlights the need for better regional litter management measures.

Current Place of SGLT2i in the Management of Heart Failure: An Expert Opinion from India

Heart failure (HF) is a global health concern that is prevalent in India as well. HF is reported at a younger age in Indian patients with comorbidity of type 2 diabetes (T2DM) in approximately 50% of patients. Sodium-glucose cotransporter-2 inhibitors (SGLT2i), originally approved for T2DM, are new guideline-recommended and approved treatment strategies for HF. Extensive evidence highlights that SGLT2i exhibits profound cardiovascular (CV) benefits beyond glycemic control. SGLT2i, in conjunction with other guideline-directed medical therapies (GMDT), has additive effects in improving heart function and reducing adverse HF outcomes. The benefits of SGLT2i are across a spectrum of patients, with and without diabetes, suggesting their potential place in broader HF populations irrespective of ejection fraction (EF). This consensus builds on the updated evidence of the efficacy and safety of SGLT2i in HF and recommends its place in therapy with a focus on Indian patients with HF.

The Promise of Cilnidipine in Hypertension with Comorbidities: National Consensus Statement: National Consensus Group Comprises Cardiologists, Nephrologists, and Diabetologists from India in a National Meet at New Delhi held on 22nd May 2022

The rapidly increasing burden of hypertension is responsible for premature deaths from cardiovascular disease (CVD), renal disease, and stroke, with a tremendous public health and financial burden. Hypertension detection, treatment, and control vary worldwide; it is still low, particularly in low- and middle-income countries (LMICs). High blood pressure (BP) and CVD risk have a strong, linear, and independent association. They contribute to alarming numbers of all-cause and CVD deaths. A major culprit for increased hypertension is sympathetic activity, and further complications of hypertension are heart failure, ischemic heart disease (IHD), stroke, and renal failure. Now, antihypertensive interventions have emerged as a global public health priority to reduce BP-related morbidity and mortality. Calcium channel blockers (CCB) are highly effective vasodilators. and the most common drugs used for managing hypertension and CVD. Cilnidipine, with both L- and N-type calcium channel blocking activity, is a promising 4th generation CCB. It causes vasodilation via L-type calcium channel blockade and inhibits the sympathetic nervous system (SNS) via N-type calcium channel blockade. Cilnidipine, which acts as a dual L/N-type CCB, is linked to a reduced occurrence of pedal edema compared to amlodipine, which solely blocks L-type calcium channels. The antihypertensive properties of cilnidipine are very substantial, with low BP variability and long-acting properties. It is beneficial for hypertensive patients to deal with morning hypertension and for patients with abnormal nocturnal BP due to exaggerated sympathetic nerve activation. Besides its BP-lowering effect, it also exhibits organ protection via sympathetic nerve inhibition and renin-angiotensin-aldosterone system inhibition; it controls heart rate and proteinuria. Reno-protective, neuroprotective, and cardioprotective effects of cilnidipine have been well-documented and demonstrated.

Role of Bisoprolol in Heart Failure Management: A Consensus Statement from India

In India, heart failure (HF) is an important health concern affecting younger age groups than the western population. A limited number of Indian patients receive guideline-directed medical therapy (GDMT). Selective β-1 blockers (BB) are one of the GDMTs in HF and play an important role by decreasing the sympathetic overdrive. The BB reduces heart rate (HR) reverse the adverse cardiac (both ventricular and atrial), vascular, and renovascular remodeling seen in HF. Bisoprolol, a β-1 blocker, has several advantages and can be used across a wide spectrum of HF presentations and in patients with HF and comorbid conditions such as coronary artery disease (CAD), atrial fibrillation (AF), post-myocardial infarction (MI), uncontrolled diabetes, uncontrolled hypertension, and renal impairment. Despite its advantages, bisoprolol is not optimally utilized for managing HF in India. This consensus builds on updated evidence on the efficacy and safety of bisoprolol in HF and recommends its place in therapy with a focus on Indian patients with HF.

A cup half full: the first assessment on the distribution, ecology and need for conservation of the threatened Neptune's cup sponge, Cliona patera, in the Gulf of Thailand

The Neptune's cup sponge is an iconic species found in marine soft sediment habitats in the Indo-West Pacific, with a history of overharvesting and extreme population declines. Access to SCUBA diving surveys has allowed for its rediscovery at Singapore, its type locality; however, with fewer than ten living individuals documented in the twenty-first century, the species is believed to be in need of conservation. Here, we share the results from surveys across the Gulf of Thailand, allowing for a documentation of 29 additional individuals, with information on their ecology and distribution. Of the 29 individuals, extensive damage or mortality caused by marine debris is recorded for six individuals, and one further individual is believed to be lost due to an unknown cause. Documented threats from the Gulf of Thailand differ from those in Singapore; however, low population sizes and poor connectivity remain a significant concern for the survival of the species.

The Power and Promise of Angiotensin Receptor Neprilysin Inhibitor (ARNI) in Heart Failure Management: National Consensus Statement

;Heart failure (HF) is a huge global public health task due to morbidity, mortality, disturbed quality of life, and major economic burden. It is an area of active research and newer treatment strategies are evolving. Recently angiotensin receptor-neprilysin inhibitor (ARNI), a class of drugs (the first agent in this class, Sacubitril-Valsartan), reduces cardiovascular mortality and morbidity in chronic HF patients with reduced left ventricular ejection fraction (LVEF). Positive therapeutic effects have led to a decrease in cardiovascular mortality and HF hospitalizations (HFH), with a favorable safety profile, and have been documented in several clinical studies with an unquestionable survival benefit with ARNI, Sacubitril-Valsartan. This consensus statement of the Indian group of experts in cardiology, nephrology, and diabetes provides a comprehensive review of the power and promise of ARNI in HF management and an evidence-based appraisal of the use of ARNI as an essential treatment strategy for HF patients in clinical practice. Consensus in this review favors an early utility of Sacubitril-Valsartan in patients with HF with reduced EF (HFrEF), regardless of the previous therapy being given. A lower rate of hospitalizations for HF with Sacubitril-Valsartan in HF patients with preserved EF who are phenotypically heterogeneous suggests possible benefits of ARNI in patients having 40-50% of LVEF, frequent subtle systolic dysfunction, and higher hospitalization risk.

Unmet Need for Further LDL-C Lowering in India despite Statin Therapy: Lipid Association of India Recommendations for the Use of Bempedoic Acid

Lipid-lowering therapy plays a crucial role in reducing adverse cardiovascular (CV) events in patients with established atherosclerotic cardiovascular disease (ASCVD) and familial hypercholesterolemia. Lifestyle interventions along with high-intensity statin therapy are the first-line management strategy followed by ezetimibe. Only about 20-30% of patients who are on maximally tolerated statins reach recommended low-density lipoprotein cholesterol (LDL-C) goals. Several factors contribute to the problem, including adherence issues, prescription of less than high-intensity statin therapy, and de-escalation of statin dosages, but in patients with very high baseline LDL-C levels, including those with familial hypercholesterolemia and those who are intolerant to statins, it is critical to expand our arsenal of LDL-C-lowering medications. Moreover, in the extreme risk group of patients with an LDL-C goal of ≤30 mg/dL according to the Lipid Association of India (LAI) risk stratification algorithm, there is a significant residual risk requiring the addition of non-statin drugs to achieve LAI recommended targets. This makes bempedoic acid a welcome addition to the existing non-statin therapies such as ezetimibe, bile acid sequestrants, and PCSK9 inhibitors. A low frequency of muscle-related side effects, minimal drug interactions, a significant reduction in high-sensitivity C-reactive protein (hsCRP), and a lower incidence of new-onset or worsening diabetes make it a useful adjunct for LDL-C lowering. However, the CV outcomes trial results are still pending. In this LAI consensus document, we discuss the pharmacology, indications, contraindications, advantages, and evidence-based recommendations for the use of bempedoic acid in clinical practice.

Contrasting coral community structures between natural and artificial substrates at Koh Tao, Gulf of Thailand

Concrete cubic frames and decommissioned steel naval vessels have been deployed in Thailand liberally to act as artificial substrates for coral restoration and marine recreation. We assessed recruitment at such substrate types at Koh Tao, Gulf of Thailand, and compared the community structure of scleractinian corals between artificial substrates and nearby natural reefs. Our results from a sample of 2677 recruits from nine sites highlighted significant differences in community structure between both reef types. Investigations of variables including time since deployment, distance from the natural reef, and seafloor depth revealed only the latter as a possible influencing factor. The diversity of recruits could not be explained by dynamics in coral spawning, and were found to represent groups with lower structural complexity. Our results suggest that coral community structure on artificial and natural reefs differs and supports distinct ecological and functional roles.

Management of Dyslipidaemia for the Prevention of Stroke: Clinical Practice Recommendations from the Lipid Association of India

Stroke is the second most common cause of death worldwide. The rates of stroke are increasing in less affluent countries predominantly because of a high prevalence of modifiable risk factors. The Lipid Association of India (LAI) has provided a risk stratification algorithm for patients with ischaemic stroke and recommended low density lipoprotein cholesterol (LDL-C) goals for those in a very high risk group and extreme risk group (category A) of <50 mg/dl (1.3 mmol/l) while the LDL-C goal for extreme risk group (category B) is ≤30 mg/dl (0.8 mmol/l). High intensity statins are the first-line lipid lowering therapy. Non-statin therapy like ezetimibe and proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors may be added as an adjunct to statins in patients who do not achieve LDL-C goals statins alone. In acute ischaemic stroke, high intensity statin therapy improves neurological and functional outcomes regardless of thrombolytic therapy. Although conflicting data exist regarding increased risk of intracerebral haemorrhage (ICH) with statin use, the overall benefit risk ratio favors long-term statin therapy necessitating detailed discussion with the patient. Patients who have statins withdrawn while being on prior statin therapy at the time of acute ischaemic stroke have worse functional outcomes and increased mortality. LAI recommends that statins be continued in such patients. In patients presenting with ICH, statins should not be started in the acute phase but should be continued in patients who are already taking statins. ICH patients, once stable, need risk stratification for atherosclerotic cardiovascular disease (ASCVD).

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.

An updated inventory of sea slugs from Koh Tao, Thailand, with notes on their ecology and a dramatic biodiversity increase for Thai waters

Improved access to field survey infrastructure throughout South-East Asia has allowed for a greater intensity of biodiversity surveys than ever before. The rocky bottoms and coral reef habitats across the region have been shown to support some of the highest sea slug biodiversity on the planet, with ever increasing records. During the past ten years, intensive SCUBA surveys have been carried out at Koh Tao, in the Gulf of Thailand, which have yielded remarkable findings in sea slug biology and ecology. In this work a brief history of sea slug biodiversity research from Thailand is covered and a complete inventory of sea slugs from Koh Tao, Gulf of Thailand is provided. This inventory is based on surveys from 2012 to 2020, with previously unreported findings since 2016. Habitat specificity and species-specific ecology are reported where available with a focused comparison of coral reef habitats and deeper soft-sediment habitats. The findings contribute 90 new species records for Thai waters (92 for the Gulf of Thailand) and report a remarkable consistency in the proportional diversity found to be exclusive to one habitat type or another. Additionally, taxonomic remarks are provided for species documented from Koh Tao that have not been discussed in past literature from Thailand, and a summary of previous records in the Indo-West Pacific is given.

On the Plakobranchidae (Gastropoda, Sacoglossa) from soft sediment habitats of Koh Tao, Gulf of Thailand, with descriptions of two new species

Research in recent years have provided rapid advances in biogeographic and taxonomic documentation of sea slugs around the world. However, efforts are lacking in surveying most coastlines and habitats in South-East Asia. Recent studies from the Gulf of Thailand have indicated that a wealth of unexplored sea slug diversity and ecology may be gained from an investigation of soft sediment habitats beyond the reef slopes. Additionally, the waters of Koh Tao have been found to host regionally high levels of sea slug diversity with several species awaiting taxonomic clarification. In this work the initial findings of an expanded survey effort from the waters around Koh Tao are provided, with the identity of two soft sediment-associated sacoglossan species in the family Plakobranchidae being investigated. By integrating morphological and molecular analyses, the species Plakobranchusnoctisstellatussp. nov. and Elysiaaowthaisp. nov. are described and species complexes surrounding Plakobranchusocellatus van Hasselt, 1824 and Elysiajaponica Eliot, 1913 are discussed. The topics of morphological variability and the cryptic species problem are also discussed.

An unusual left ventricular outflow tract mass in a patient with systemic lupus erythematosus

A 25-year-old female, with systemic lupus erythematosus and antiphospholipid antibody syndrome, presented with exertional dyspnoea. Echocardiography showed a large (2.0 cm × 1.1 cm), echogenic, heterogeneous mass in the left ventricular outflow tract, under the aortic valve, attached to the ventricular aspect of the anterior mitral leaflet. Tiny flagellar, frond-like structures were seen attached to the surface of the mass. There was mitral regurgitation. These echocardiographic features were suggestive of a papillary fibroelastoma, but the histopathology of the excised mass revealed it to be a thrombus, which was consistent with a diagnosis of non-bacterial thrombotic endocarditis (NBTE). This case represents a rare histopathologically confirmed NBTE presenting as an unusually large mass in the left ventricular outflow tract.

Selective consumption of sacoglossan sea slugs (Mollusca: Gastropoda) by scleractinian corals (Cnidaria: Anthozoa)

Recent studies revealed that reef corals can eat large-sized pelagic and benthic animals in addition to small planktonic prey. As follow-up, we document natural ingestion of sea slugs by corals and investigate the role of sacoglossan sea slugs as possible prey items of scleractinian corals. Feeding trials were carried out using six sacoglossan species as prey, two each from the genera Costasiella, Elysia and Plakobranchus, and four free-living solitary corals (Danafungia scruposa, Fungia fungites, Pleuractis paumotensis and Heteropsammia cochlea) as predators. Trials were carried out under both in-situ and ex-situ conditions with the aim to observe ingestion and assess signs of prey consumption based on tissue loss of prey individuals over time. Significant differences were observed in both ingestion time and consumption state of prey between prey species, with three of them being ingested more rapidly and preferentially consumed over the others. Additionally, prey size was found to be a significant factor with larger prey (>12 mm) being ingested more slowly and rarely than smaller ones (<6 mm and 6-12 mm). Comparisons of consumption capability among predators showed no significant difference with all coral species showing similar preferences for prey species. While no specific mechanism of prey capture is proposed, we also document instances of kleptoparisitism and resuspension of prey items by wrasses. This study highlights the important distinction between opportunistic prey capture and true predation events.

The formerly enigmatic Unidentiidae in the limelight again: a new species of the genus Unidentia from Thailand (Gastropoda: Nudibranchia)

An integrative molecular and morphological study is presented for the family Unidentiidae. Molecular phylogenetic analyses were conducted with the inclusion of all previous and newly obtained molecular data for the family Unidentiidae Millen Hermosillo 2012. A new species of the genus Unidentia Millen Hermosillo 2012, U. aliciae sp. nov., is described from Thailand as part of an inventory of sea slugs at Koh Tao. All up-to-date available morphological data for the species of the genus Unidentia is for the first time summarized. Morphological differences among the different species of Unidentia are clarified showing that every species has its own distinguishable morphological traits. According to the new molecular and morphological data, the family Unidentiidae is re-confirmed as a well-supported taxon of the aeolidacean nudibranchs. The taxonomy and phylogeny of the Aeolidacea in the light of the family Unidentiidae is briefly discussed and necessity of a fine-scale and narrowly-defined taxa approach instead of a ''superlumping'' one is highlighted.

The extraordinary genus Myja is not a tergipedid, but related to the Facelinidae s. str. with the addition of two new species from Japan (Mollusca, Nudibranchia)

Morphological and molecular data are presented for the first time in an integrative way for the genus Myja Bergh, 1896. In accordance with the new molecular phylogenies, the traditional Facelinidae is paraphyletic. Herein is presented the phylogenetic placement of true Facelinidae s. str., including the first molecular data for F.auriculata (Müller, 1776), type species of the genus Facelina Alder & Hancock, 1855. The taxonomic history of F.auriculata is reviewed. The genus Myja is related to the clade Facelinidae s. str., but shows disparate morphological traits. Two new species of the genus Myja, M.karinsp. n., and M.hyotansp. n., are described from the Pacific waters of Japan (middle Honshu), and M.cf.longicornis Bergh, 1896 is investigated from Thailand. According to molecular analysis and review of available morphological information, the genus Myja contains more hidden diversity. The family-level relationship within aeolidacean nudibranchs with emphasis on the family Facelinidae is outlined. The problem of the relationship between Facelinidae Bergh, 1889 and Glaucidae Gray, 1827 is discussed. The family Glaucidae has precedence over Facelinidae and is phylogenetically related to the core group of Facelinidae s. str., but has a profoundly modified aberrant external morphology, thus making a purely molecular-based approach to the taxonomy an unsatisfactory solution. To accommodate recently discovered hidden diversity within glaucids, the genus Glaucilla Bergh, 1861 is restored. The family Facelinidae s. str. is separate from, and not closely related to, a clade containing the genera Dondice Marcus, 1958, Godiva MacNae 1954, Hermissenda Bergh, 1879, and Phyllodesmium Ehrenberg, 1831 (= Myrrhine Bergh, 1905). The oldest valid available name for the separate ex-facelinid paraphyletic clade that contains several facelinid genera is Myrrhinidae Bergh, 1905, and resurrection of this family name under provision of the ICZN article 40.1 can preliminarily solve the problem of paraphyly of the traditional Facelinidae. “Facelinidae” s. l. needs to be further divided into several separate families, pending further study.

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.