Geographic pathology revisited: development of an atlas of cancer in India

Information on 217,174 microscopically diagnosed cancers diagnosed in 2001-2002 was collected from pathology laboratories in 68 districts across India. Data collection took place primarily via the Internet. Average annual age-adjusted incidence rates for microscopically diagnosed cases (MAAR) by gender and site were calculated for each of the 593 districts in the country. The rates were compared to those from established population based cancer registries (PBCR). In 82 districts, the MAAR for 'all cancer sites' was above a "completeness" threshold of 36.2/100,000 (based on results of a rural PBCR). The results confirmed some known features of the geography of cancer in India, and brought to light new ones. Cancers of the mouth and tongue are particularly frequent in both genders in the southern states. Very high rates of nasopharynx cancer were found in the northeastern states (Nagaland, Manipur). There was clear geographic correlation between the rates of cervical and penile cancer, and a high rate of stomach and lung cancer (in both genders) in many districts of Mizoram State. The area of high risk for gallbladder cancer seems larger than suspected previously, involving a wide band of northern India. There is a belt of high incidence of thyroid cancer in females in southwest coastal districts. Other than identifying possible existence of high-risk areas of specific cancers, our study has recognized places where PBCR could be established. The study was remarkably cost-effective and the electronic data-capture methodology provides a model for health informatics in the setting of a developing country.

Tobacco water: a special form of tobacco use in the Mizoram and Manipur states of India

BACKGROUND

Tuibur and hidakphu are watery tobacco products made by passing tobacco smoke through water. These have neither been described in the health literature nor are there any reports of epidemiological studies on these products. We collected information on the use of these products in Mizoram and Manipur.

METHODS

We conducted two surveys. In the first, we spoke to personnel involved in tobacco water manufacturing, marketing and sale. In the second, we carried out a house to house survey of adults on the attitude and behaviour towards the use of tobacco products in 25 randomly selected villages each in Aizawl district of Mizoram and Churchandpur district of Manipur.

RESULTS

About 7% of persons surveyed in Aizawl (872 of 12 185) and Churchandpur (139 of 2137) used tobacco water, which is stored and sold in bottles. It is sipped and retained in the mouth for 5-10 minutes and then spat out. Among tobacco water users, about 90% of users in Churchandpur and about 40% in Aizawl sipped tobacco water more than 5 times a day. The use of other tobacco products in both districts was also high.

CONCLUSION

The use of tobacco water has been a part of the culture of some communities in Mizoram and Manipur for a long time. These communities also have a very high incidence of tobacco use. To discourage the use of such tobacco products, these communities should be educated about the harmful effects of tobacco use on a priority.

Extracranial carotid aneurysm related to pregnancy

Carotid aneurysms are rare, and pregnancy-related carotid aneurysms are rarer still. We report the case of an extracranial carotid aneurysm related to pregnancy. It was noted in the 20th week of gestation, and was uncomplicated. Surgery was successfully performed urgently to preempt embolism or rupture. The patient had a full-term normal delivery. The graft is patent, and the patient has no symptoms at 28-month follow-up. To the best of our knowledge, this case represents the first successful repair of an extracranial carotid aneurysm during pregnancy.

Epidemiology of betel quid usage

Betel quid chewing is an ancient practice common in many countries of Asia and among migrated communities in Africa, Europe and North America. It enjoys complete social acceptance in many societies and is also popular among women. In its most basic form, betel quid consists of betel leaf (Piper betel), areca nut, the main psychoactive ingredient, and slaked lime (calcium hydroxide). Areca nut is said to be the fourth most commonly used psychoactive substance in the world, after caffeine, nicotine and alcohol. There are a great variety of ingredients and ways of preparing betel quid in different countries. In some, particularly in India, tobacco is added to the quid. In recent years, commercially-manufactured non-perishable forms of betel quid (pan masala or betel quid mixtures and gutka), not containing betel leaf, have been marketed. Within a short period of about 2 decades, this industry has risen in value to several hundred US million dollars. Use of areca nut in any form is not safe for oral health; the use of commercially manufactured forms seems even riskier.

Tobacco use among students in the eight North-eastern states of India

OBJECTIVES

To obtain baseline information about prevalence of tobacco use among school children in eight states in the North-eastern part of India.

MATERIAL AND METHODS

A two-stage probability sample of students in grades 8-10 corresponding to 13 to 15 years of age was selected in each state and surveyed through an anonymous, self-administered questionnaire.

RESULTS

Among the sampled schools, the school response rate was 100% in all states except Tripura (92%) and Meghalaya (96%). Among the eligible students, over 80% participated in the survey. Among the respondents, the proportion of boys ranged between 50% to 55%. Ever tobacco users ranged from 75.3% (Mizoram) to 40.1% (Assam). Over 65% of users reported initiation at 10 years of age or earlier in all states except Mizoram (23.1%). The range of current tobacco use (any product) was 63% (Nagaland) to 36.1% (Assam). Current smokeless tobacco use ranged from 49.9% (Nagaland) to 25.3% (Assam). Mizoram reported the highest current smoking (34.5%, mainly cigarette) and Assam reported the lowest (19.7%, again mainly cigarette). Current smoking among girls (8.3% to 28.2%) was also quite high. Over half of current cigarette smokers (53.2% to 96.3%) and a high proportion of current smokeless tobacco users (38.5% to 80.8%) reported feeling like having tobacco first thing in the morning. Only about 20% of students reported having been taught in school about the dangers of tobacco use, except in Mizoram (around 50%). Tobacco use by parents and close friends was positively associated with students' current tobacco use.

CONCLUSIONS

Tobacco use including smoking was very high, even among girls, in all eight states in the North-eastern part of India. Signs of tobacco dependency were already visible in these students, more among those who smoked. In general schools did not educate students about the hazards of tobacco use.

Bilateral microphthalmia with cyst, facial clefts, and limb anomalies: a new syndrome with features of Waardenburg syndrome, cerebro-oculo-nasal syndrome, and craniotelencephalic dysplasia

We report a patient with bilateral microphthalmia with cyst, limb anomalies, and multiple facial malformations. This patient has clinical features similar to Waardenburg ophthalmo-acromelic syndrome, cerebro-oculo-nasal syndrome, and craniotelencephalic dysplasia. Although all of these syndromes are characterized by microphthalmia, the presently reported patient does not have the complete pattern of any of these syndromes, It is possible that he has a previously undescribed syndrome, most closely related to the cerebro-oculo-nasal syndrome with malformations outside the craniofacial region. More case reports are needed to further delineate this possibly new syndrome.

Tobacco use among school personnel in eight North-eastern states of India

AIMS

To obtain baseline information about tobacco use prevalence, knowledge and attitude among school personnel in Eight North-eastern states of India (Assam, Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim, and Tripura).

MATERIAL AND METHODS

A sample of schools with probability proportional to the enrollment in grades 8-10. Anonymous self-administered questionnaire was used for all personnel working in the selected schools.

RESULTS

The school response rate was 100% in all states except Meghalaya (96%) and Tripura (92%). Over 70% of school personnel participated in the survey, the proportion of men being 56% (Meghalaya) to 83% (Assam). The prevalence of daily smoking ranged from 25.9% (Mizoram) to 12.8% (Arunachal Pradesh) and of smokeless tobacco use from 57.8% (Mizoram) to 10.7% (Assam). Daily smoking among men and women was similar in five states but not in Arunachal Pradesh (men 15.0%, women 4.0%), Nagaland (men 18.7%, 5.0%), and Tripura (men 18.6%, women 0.4%). In four states cigarette was the most prevalent form of smoking (range 41% to 55%) whereas in other four states it was bidi (range 34% to 53%). Although the number of women was small, cigarettes smoking was reported more among women than men in four states: Assam, Arunachal Pradesh, Manipur, and Nagaland. Over 50% of current smokeless tobacco users reported using betel quid in six states, except Mizoram (20%) and Sikkim (16%).

CONCLUSION

Tobacco use among school personnel was high. High smoking rates reported by women were unexpected.

Descriptive epidemiology of body mass index of an urban adult population in western India

STUDY OBJECTIVE

To describe height, weight, and body mass index (BMI) of the adult urban population in Mumbai, western India and to estimate the prevalence and severity of thinness and overweight in this population. To describe the association of BMI with education, age, and tobacco habits in an urban Indian population.

DESIGN

Cross sectional representative survey of 99 598 adults (40 071 men and 59 527 women).

SETTING

The survey was carried out in the city of Mumbai (formerly known as Bombay) in western India.

PARTICIPANTS

Men and women aged > or =35 years who were residents of the main city of Mumbai.

MAIN RESULTS

The mean height, weight, and BMI were 161.0 (SD 6.7) cm, 56.7 (SD 11.0) kg, and 21.8 (SD 3.8) kg/m(2) for men and 148.0 (SD 6.2) cm, 49.8 (SD 11.2) kg, and 22.7 (SD 4.7) kg/m(2) for women, respectively. Some 19% of men and women were thin (BMI<18.5 kg/m(2)), while 19% of men and 30% of women were overweight (BMI> or =25kg/m(2)). Multivariable logistic regression analyses showed that age, level of education, and tobacco use were independently associated with BMI. The odds ratio (OR) and 95% confidence intervals (CI) for thinness (BMI<18.5 kg/m(2)) were OR 6.52, 95%CI 5.38 to 7.89 for men and OR 4.83, 95%CI 3.71 to 6.28 for women, respectively, (p<0.001) for the lowest level of education (illiterate group). The OR and 95%CI for overweight were 2.25, 2.20 to 2.58 for college educated men and 1.90, 1.64 to 2.20 for college educated women, respectively, p<0.001. Both smoking (2.33, 2.09 to 2.59; 2.89, 1.77 to 4.72 for men and women, respectively, p<0.001) and smokeless tobacco use (1.65, 1.52 to 1.80; 2.26, 2.14 to 2.38 for men and women, respectively p<0.0001) were significantly associated with low BMI.

CONCLUSIONS

Sequelae of thinness and overweight represent major public health problems. The results of this study, indicating an equal prevalence of thinness and overweight in an urban area and their association with age, level of education, and tobacco use raise concerns of an emerging public health crisis in urban India.

Global epidemiology of areca nut usage

A substantial proportion of the world's population is engaged in chewing areca nut and the habit is endemic throughout the Indian subcontinent, large parts of south Asia and Melanesia. A large variety of ingredients, including tobacco, may be used along with areca nut constituting a betel quid. The composition and method of chewing can vary widely from country to country and these population variations are described in this review. Some populations are known to use areca nut without tobacco providing good opportunities to further research the carcinogenecity of areca nut. Some interesting trends on chewing patterns have emerged from recent data, suggesting a decline in the habit in some countries such as Thailand while the prevalence of areca nut use is rising in India and Taiwan.

An epidemiological study of tori among 667 dental outpatients in Trinidad & Tobago, West Indies

AIM

To study the prevalence of tori amongst dental outpatients, the ethnic and sex variations in their distribution, and their clinical features.

SETTING

The School of Dentistry, St. Augustine, Trinidad & Tobago.

PARTICIPANTS

667 consecutive dental outpatients representing three different ethnic groups of the country.

METHODS

Clinical examination for and recording of tori indicating their location, extent and clinical features and the age, sex and ethnic grouping of the patient.

RESULTS

The overall prevalence of tori was 12.3 per cent.

CONCLUSIONS

There were no significant differences in the prevalence among the African, Indian or mixed ethnic groups of patients examined. There seemed to be strong link between the coexistence of palatal and mandibular tori.

Attenuation of renal ischemia-reperfusion injury in rats by allopurinol and prostaglandin E1

50 Sprague-Dawley rats were used to study the effect of allopurinol and prostaglandin E1 (PGE1) on renal ischemia-reperfusion injury. They underwent left renal ischemia for 1 h and reperfusion. A right nephrectomy was performed, and 5 groups were made. Group AP received allopurinol 50 mg/kg and PGE1 20 micrograms/kg; group A, allopurinol; group P, PGE1; group C, control, and group S, sham group. Five animals from each group were used to study renal functions and 5 for renal histology. The serum creatinine values were lower in the treatment groups compared to the controls on days 1-3 and 7 (p < 0.05). The blood urea nitrogen values showed a similar trend. Maximum histological damage was seen in group C, followed by groups A, P and AP, in this order. We conclude that allopurinol and PGE1 attenuate renal ischemia-reperfusion injury in rats.

Validation of real-time three-dimensional echocardiography for quantifying left ventricular volumes in the presence of a left ventricular aneurysm: in vitro and in vivo studies

OBJECTIVES

To validate the accuracy of real-time three-dimensional echocardiography (RT3DE) for quantifying aneurysmal left ventricular (LV) volumes.

BACKGROUND

Conventional two-dimensional echocardiography (2DE) has limitations when applied for quantification of LV volumes in patients with LV aneurysms.

METHODS

Seven aneurysmal balloons, 15 sheep (5 with chronic LV aneurysms and 10 without LV aneurysms) during 60 different hemodynamic conditions and 29 patients (13 with chronic LV aneurysms and 16 with normal LV) underwent RT3DE and 2DE. Electromagnetic flow meters and magnetic resonance imaging (MRI) served as reference standards in the animals and in the patients, respectively. Rotated apical six-plane method with multiplanar Simpson's rule and apical biplane Simpson's rule were used to determine LV volumes by RT3DE and 2DE, respectively.

RESULTS

Both RT3DE and 2DE correlated well with actual volumes for aneurysmal balloons. However, a significantly smaller mean difference (MD) was found between RT3DE and actual volumes (-7 ml for RT3DE vs. 22 ml for 2DE, p = 0.0002). Excellent correlation and agreement between RT3DE and electromagnetic flow meters for LV stroke volumes for animals with aneurysms were observed, while 2DE showed lesser correlation and agreement (r = 0.97, MD = -1.0 ml vs. r = 0.76, MD = 4.4 ml). In patients with LV aneurysms, better correlation and agreement between RT3DE and MRI for LV volumes were obtained (r = 0.99, MD = -28 ml) than between 2DE and MRI (r = 0.91, MD = -49 ml).

CONCLUSIONS

For geometrically asymmetric LVs associated with ventricular aneurysms, RT3DE can accurately quantify LV volumes.

Sources of variability in dietary intake in two distinct regions of rural India: implications for nutrition study design and interpretation

OBJECTIVE

Limited inter-person variability in nutrient intake hampers epidemiologic studies of diet-disease relationships. Despite conjecture about non-traditional study bases providing large inter-person differences, virtually nothing is known about variations in nutrient intake outside of Europe and North America. The current study was conducted in India to determine sources of variability in the intakes of nutrients thought to be of public health importance.

DESIGN

Adult subjects in Gujarat (North India; n=60) and in Kerala (South India, n=60) were administered 24 h diet recall interviews six and eight times, respectively, over a 1 y period. To assess subject (inter-person) and residual (intra-person) contributions to variance, regression models were fit to the data. From this, the variance ratio (VR, total within or intra-person: total between or inter-person) was computed.

SETTING

Rural communities in North and South India.

RESULTS

In both regions, inter-person variability was larger than that observed in the West. This was most pronounced in Gujarat, for which the VR was <1.0 for seven of the 12 energy-adjusted nutrient intakes in both men and women. In analyses of the combined data, region accounted for >20% of variance for fat, iron, copper, zinc, beta-carotene and riboflavin in both men and women. With the region term removed from this model, virtually all of the variability ascribed to region contributed to inter-person variability.

CONCLUSIONS

The relatively large inter-person variability observed here could contribute to improved 'resolution' of diet-outcome relationships in epidemiologic studies. While this applies to data from each region, it was especially evident in analyses of the combined data.

Role of selective intra-operative cholangiography during cholecystectomy

BACKGROUND

The use of routine intra-operative cholangiography (IOC) remains controversial. This prospective study was carried out to determine whether to perform selective or routine IOC in patients undergoing cholecystectomy for gallstones.

METHODS

All consecutive patients undergoing open cholecystectomy over a 16-month period were included in the present study. They were divided into two groups based on the absence (n = 79) or presence (n = 55) of indicators of choledocholithiasis. All patients were subjected to cholangiography. Each indicator, subsets of indicators and all indicators combined were evaluated for their ability to predict choledocholithiasis.

RESULTS

There would be only two missed stones (1.5%) if selective cholangiography was to be practised. Intra-operative cholangiography had a positive predictive value of 100%. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of all the indicators combined were 93.5%, 84.6%, 74.5%, 97.5% and 88.0%, respectively. The best indicators in each subset were jaundice, common bile duct diameter as assessed by ultrasonography, and a palpable stone during surgery with NPV of 82.7%, 91.1% and 96.8%, respectively.

CONCLUSION

Routine IOC during cholecystectomy is not essential for the prevention of retained stones. A combination of the various indicators of choledocholithiasis can be used to select patients for cholangiography.

Cohort study of all-cause mortality among tobacco users in Mumbai, India

INTRODUCTION

Overall mortality rates are higher among cigarette smokers than non-smokers. However, very little is known about the health effects of other forms of tobacco use widely prevalent in India, such as bidi smoking and various forms of smokeless tobacco (e.g. chewing betel-quid). We therefore carried out a cohort study in the city of Mumbai, India, to estimate the relative risks for all-cause mortality among various kinds of tobacco users.

METHODS

A baseline survey of all individuals aged > or = 35 years using voters' lists as a selection frame was conducted using a house-to-house approach and face-to-face interviews.

RESULTS

Active follow-up of 52,568 individuals in the cohort was undertaken 5-6 years after the baseline study, and 97.6% were traced. A total of 4358 deaths were recorded among these individuals. The annual age-adjusted mortality rates were 18.4 per 1000 for men and 12.4 per 1000 for women. For men the mortality rates for smokers were higher than those of non-users of tobacco across all age groups, with the difference being greater for lower age groups (35-54 years). The relative risk was 1.39 for cigarette smokers and 1.78 for bidi smokers, with an apparent dose-response relationship for frequency of smoking. Women were basically smokeless tobacco users, with the relative risk among such users being 1.35 and a suggestion of a dose-response relationship.

DISCUSSION

These findings establish bidi smoking as no less hazardous than cigarette smoking and indicate that smokeless tobacco use may also cause higher mortality. Further studies should be carried out to obtain cause-specific mortality rates and relative risks.

Mouth cancer in India: a new epidemic?

Oral cancer has been traditionally described as a major form of cancer in India although on the basis of cancer registry data, it was thought that the incidence has decreased. There are several recent reports in the literature, however, predicting an increase in mouth cancer incidence in India. This prediction is based upon observation of an increasing prevalence of oral submucous fibrosis, especially in younger individuals, caused by gutka, an industrially manufactured food item. A comparison of the age distribution of recently reported oral submucous fibrosis cases and incident cases reported in the past clearly establishes that the disease is now occurring at much younger ages. A comparison of the age specific incidence rates of mouth cancer (ICD 143-5) during 1983-87 and 1995 in the city of Ahmedabad shows that the incidence has significantly increased in the younger population (< 50 years). Since tongue cancer (ICD 141) does not show a similar increase, it is concluded that the increase in mouth cancer incidence is real. Urgent public health measures are required to curb this new but avoidable epidemic.