Impact of chewing betel-nut (Areca catechu) on liver cirrhosis and hepatocellular carcinoma: a population-based study from an area with a high prevalence of hepatitis B and C infections. Public Health Nutr. 2009;12:129-135. [PMID: 18410705 DOI: 10.1017/s1368980008002073]

Arecoline-Induced Hepatotoxicity in Rats: Screening of Abnormal Metabolic Markers and Potential Mechanisms

Arecoline is a pyridine alkaloid derived from areca nut in the Arecaceae family. It has extensive medicinal activity, such as analgesic, anti-inflammatory, and anti-allergic. However, the toxicity of Arecoline limits its application. Most current studies on its toxicity mainly focus on immunotoxicity, carcinogenesis, and cancer promotion. However, there are few systematic studies on its hepatotoxicity and mechanisms. Therefore, this research explored the mechanism of hepatotoxicity induced by Arecoline in rats and analyzed endogenous metabolite changes in rat plasma by combining network toxicology with metabolomics. The differential metabolites after Arecoline exposure, such as D-Lysine, N4-Acetylaminobutanal, and L-Arginine, were obtained by metabolomics study, and these differential metabolites were involved in the regulation of lipid metabolism, amino acid metabolism, and vitamin metabolism. Based on the strategy of network toxicology, Arecoline can affect the HIF-1 signaling pathway, MAPK signaling pathway, PI3K-Akt signaling pathway, and other concerning pathways by regulating critical targets, such as ALB, CASP3, EGFR, and MMP9. Integration of metabolomics and network toxicology results were further analyzed, and it was concluded that Arecoline may induce hepatotoxicity by mediating oxidative stress, inflammatory response, energy and lipid metabolism, and cell apoptosis.

Diabetes and obesity and risk of pyogenic liver abscess

Few literatures discussed the relationship of glycemic control and body mass index (BMI) with the risk of pyogenic liver abscess. We conducted a population-based cohort study using participants of a community-based health screening program in Taiwan from 2005 to 2008 (n = 125,865). Information on fasting plasma glucose (FPG), BMI, and other potential risk factors of liver abscess were collected at baseline. Incidence of pyogenic liver abscess was ascertained using inpatient records from the National Health Insurance database. During a median 8.6 years of followed up, 192 incident cases of pyogenic liver abscess were reported. The incidence rate of pyogenic liver abscess was 70.2 and 14.7 per 100,000 in the diabetic and non-diabetic population respectively. In multivariable Cox regression analysis, the adjusted hazard ratio (HR) was 2.18 (95% confidence interval (CI) 1.22-3.90) in patients with diabetes with good glycemic control (FPG ≤ 130 mg/dl) and 3.34 (95% CI 2.37-4.72) in those with poor glycemic control (FPG > 130 mg/dl), when compared with non-diabetics. In the dose-response analysis, the risk of liver abscess increased monotonically with increasing FPG. After adjusting for diabetes and other comorbidities, overweight (25 ≤ BMI < 30) (adjusted HR: 1.43, 95% CI 1.05-1.95) and obese (BMI ≥ 30) (adjusted HR: 1.75, 95% CI 1.09-2.81) populations had a higher risk of liver abscess when compared to people with normal weight. Diabetes, especially poorly controlled disease, and high BMI were associated with higher risk of pyogenic liver abscess. Improving glycemic control and weight reduction may reduce the risk of developing pyogenic liver abscess.

Tendon Disorders in Chronic Liver Disease: A Retrospective Cohort Study in Taiwan

To investigate the relationship between chronic liver disease and tendon disorder, a retrospective cohort study was conducted using the Kaohsiung Veterans General Hospital database. Patients >18 years with newly diagnosed liver disease and with at least a two-year follow-up in the hospital were included. An equal number of 20,479 cases were enrolled in both the liver-disease and non-liver-disease groups using a propensity score matching method. Disease was defined using ICD-9 or ICD-10 codes. The primary outcome was the development of tendon disorder. Demographic characteristics, comorbidities, use of tendon-toxic drugs, and status of HBV/HCV infection were included for analysis. The results showed 348 (1.7%) and 219 (1.1%) individuals developed tendon disorder in the chronic liver disease group and non-liver-disease group. Concomitant use of glucocorticoids and statins may have further raised the risk of tendon disorder in the liver disease group. The co-existence of HBV/HCV infection did not increase the risk of tendon disorder in the patients with liver disease. Considering these findings, physicians should be more aware of tendon issues in advance, and a prophylactic strategy should be adopted in patients with chronic liver disease.

Systemic and Local Effects Among Patients With Betel Quid-Related Oral Cancer

The major predisposing factors of developing oral cancer include smoking, alcohol drinking, and betel quid chewing. Betel quid chewing could cause the abrasion and damage of oral mucosa by crude fibers, chemical insults by additive slaked lime, and arecoline from areca nut. These would lead to the local consequence of oral submucosal fibrosis, which is regarded clinically as a precancer lesion and a major cause of trismus. In addition, the components and additives in betel quid contain chemical toxins and carcinogens, which would further affect the oral mucosa and gradually develop a malignancy. Following literature review, aside from having a greater total tumor burden and more local diseases in the oral cavity and digestive tract, patients with betel quid-related oral cancer also have more systemic diseases from metabolic syndrome, hypertension, cardiovascular disease, type II diabetes mellitus, and obesity than those without this habit. In conclusion, those patients who have the history of smoking, alcohol drinking, and betel quid chewing would present much more unique clinical characteristics than those who only have a history of smoking and alcohol drinking. More attention should therefore be paid to pretreatment evaluation, treatment strategy, and posttreatment follow-up among betel quid chewers.

Metabolism of the areca alkaloids - toxic and psychoactive constituents of the areca (betel) nut

Areca nut (AN) is consumed by millions of people for its therapeutic and psychoactive effects, making it one of the most widely self-administered psychoactive substances in the world. Even so, AN use/abuse is associated with myriad oral and systemic side effects, affecting most organ systems in the body. Alkaloids abundant in the nut (e.g. arecoline, arecaidine, guvacoline, and guvacine), collectively called the areca alkaloids, are presumably responsible for the major pharmacological effects experienced by users, with arecoline being the most abundant alkaloid with notable toxicological properties. However, the mechanisms of arecoline and other areca alkaloid elimination in humans remain poorly documented. Therefore, the purpose of this review is to provide an in-depth review of areca alkaloid pharmacokinetics (PK) in biological systems, and discuss mechanisms of metabolism by presenting information found in the literature. Also, the toxicological relevance of the known and purported metabolic steps will be reviewed. In brief, several areca alkaloids contain a labile methyl ester group and are susceptible to hydrolysis, although the human esterase responsible remains presumptive. Other notable mechanisms include N-oxidation, glutathionylation, nitrosamine conversion, and carbon-carbon double-bond reduction. These metabolic conversions result in toxic and sometimes less-toxic derivatives. Arecoline and arecaidine undergo extensive metabolism while far less is known about guvacine and guvacoline. Metabolism information may help predict drug interactions with human pharmaceuticals with overlapping elimination pathways. Altogether, this review provides a first-of-its-kind comprehensive analysis of AN alkaloid metabolism, adds perspective on new mechanisms of metabolism, and highlights the need for future metabolism work in the field.

Environmental Exposure to Cyanobacteria Hepatotoxins in a Pacific Island Community: A Cross-Sectional Assessment

(1) Background: Cyanobacteria produce a wide range of secondary metabolites, including tumor-promoting hepatotoxins. We recently reported evidence of an independent association between oral cyanobacteria and hepatocellular carcinoma in a U.S. population. We sought to characterize the nature, sources, and health correlates of cyanotoxin exposure in the U.S. Pacific Island territory of Guam, which has a high incidence of liver cancer. (2) Methods: Seventy-four adult males and females were enrolled in a cross-sectional study to quantify cyanotoxins in saliva, urine, and blood and their correlation with health behaviors, medical history, and environmental exposures. Plant samples were collected from locations throughout the island. Microcystin/nodularin (MC/NOD), cylindrospermopsin (CYN), and anabaenopeptin (AB) were measured in biospecimens and in plant extracts by ELISA. (3) Results: Overall, among study participants MC/NOD were detected in 53.9% of saliva, 7.5% of urine, and 100% of serum.; CYN in 40.0% of saliva, 100.0% of urine, and 70.4% of serum; AB in 30.8% of saliva, 85% of urine, and 92.6% of serum. Salivary MC/NOD levels were significantly higher in individuals using municipal tap water as their primary source of drinking water; both salivary and urinary MC/NOD levels were higher in those not using store-bought/commercial water. Urine MC/NOD levels were highest among individuals consuming fruits and vegetables exclusively from local sources. Urine MC/NOD levels were elevated in individuals with hypertension and hyperlipidemia and salivary MC/NOD in those with recent alcohol consumption. Cyanotoxins were prevalent in plant samples including MC/NOD (46.6%), CYN (35.1%), and AB (51.7%). (4) Conclusions: Our study provides evidence that exposure to cyanobacterial hepatotoxins, including tumor promoters, may be prevalent in Guam and may originate from environmental sources. Population-based epidemiologic studies are needed to investigate the role of cyanotoxins in liver cancer development.

Peri-implant clinicoradiographic status among betel-quid chewers and controls

The aim of the present case-control observational study was to evaluate the peri-implant clinicoradiographic status among betel-quid chewers and controls. Self-reported betel-quid chewers and controls were included. Participants were categorized into 3 groups: Group-1: Individuals chewing betel-quid with tobacco; Group-2: Individuals chewing betel-quid without tobacco; and Group-3: Controls (individuals not using tobacco in any form). Demographic data was collected using a questionnaire. Periodontal and peri-implant clinicoradiologic parameters (plaque and gingival indices [PI and GI], probing depth [PD] and crestal bone loss/marginal bone loss [CBL/MBL]) were assessed. Clinical attachment loss (AL) around teeth was also assessed. Group comparisons were done using the one-way analysis of variance and Bonferroni Post-hoc adjustment tests. Correlation of periodontal and peri-implant inflammatory parameters with the duration of betel-quid chewing habit and duration of placement in the mouth were assessed using logistic regression analysis. P<0.05 was considered statistically significant. Thirty, 30 and 30 patients were included in groups 1, 2 and 3, respectively. Full-mouth PI (P<0.01), GI (P<0.01), clinical AL (P<0.01), PD (P<0.01) and mesial and distal MBL (P<0.01) were higher in groups 1 and 2 than Group-3. Peri-implant mPI (P<0.01), mGI (P<0.01), PD (P<0.01) and MBL/CBL (P<0.01) were significantly higher in groups 1 and 2 than Group-3 with no significant difference in groups 1 and 2. Betel-quid chewing habit either with or without tobacco is a risk-factor of peri-implant soft-tissue inflammation and CBL.

Cumulative Betel Quid Chewing and the Risk of Significant Liver Fibrosis in Subjects With and Without Metabolic Syndrome

Background

Betel quid chewing is associated with metabolic disorders, oral cancer, cardiovascular disease, and chronic liver diseases. Metabolic syndrome (MetS) is also a factor associated with liver fibrosis, cirrhosis, and hepatocellular carcinoma (HCC). However, studies on the relationship between betel quid and liver fibrosis while also considering MetS are lacking. The aim of this study was thus to investigate the association of betel quid chewing and liver fibrosis with MetS.

Methods

A total of 9,221 subjects were enrolled after excluding subjects <18 years of age, with past history of chronic liver diseases, cancer, significant alcohol consumption, and incomplete data. Betel nut chewing habit was classified into three groups: none, former-chewing, and current-chewing, and cumulative exposure was calculated by multiplying the duration with the quantity. Liver fibrosis was evaluated based on the NAFLD fibrosis score (NFS), which is a composite score of age, hyperglycemia, BMI, platelet count, albumin, and the AST/ALT ratio. Significant liver fibrosis was defined as NFS ≥-1.455.

Results

After adjusting for other variables, MetS was positively associated with significant liver fibrosis. Subjects with both MetS and betel quid chewing had a higher associated risk of significant liver fibrosis than those with neither MetS nor betel quid chewing (adjusted OR: 3.03, 95% CI: 2.04–4.50, p < 0.001). Betel quid chewing was associated with significant liver fibrosis (adjusted OR: 2.00, 95% CI: 1.14–3.49, p = 0.015) in subjects with MetS, but not in subjects without.

Conclusion

Metabolic syndrome increased the associated risk of significant liver fibrosis. Cumulative betel quid exposure increased the associated risk of significant liver fibrosis in subjects with MetS, but not in subjects without.

Risk of liver disease in areca nut habitual: A systematic review

Background:

Areca nut (AN) is one of the addictive substances known to cause deleterious effects on oral cavity as well as on various body organs including liver. But, scanty information is available reporting the adverse effects of AN chewing on the liver.

Aim:

To study the risk of liver disease in AN habitual based on the relevant published data.

Methods:

The literature search was performed by an electronic search of the PubMed/Medline, Scopus and Google Scholar databases using proper MESH headings and retrieved the articles published from 1998 to 2021. The eligibility criteria included: Human studies, AN habitual as study participants, use of controls and articles published in English. Data were extracted regarding characteristics of studies, characteristics of AN exposure, effect estimate and outcome of the studies.

Results:

Total 253 articles were identified from various databases and 15 studies were selected that met the inclusion criteria. Among these, thirteen studies showed an association between AN habit and attenuation of risk of liver disease as determined by relative risk/odds ratio/hazard ratio. Eleven studies described additive effect of AN and HBsAg and/or Anti hepatitis C virus status on development of liver disease. However, two of the studies showed opposite results. The heterogeneity in the study designs, exposure characteristics, outcomes and confounders precluded further meta-analysis.

Conclusion:

The association between AN chewing and an increased risk of developing liver disease is noted which necessitates the need for AN cessation campaign.

Anti-hepatitis B activities of Myanmar medicinal plants: a narrative review of current evidence

Hepatitis B is one of the major burdens for health services and is the leading cause of morbidity and mortality from cirrhosis of liver and hepatocellular carcinoma. Current treatment strategies using nucleos(t)ide analogue reverse-transcriptase inhibitors or interferons are targeted for the long-term suppression of hepatitis B DNA. However, functional cure of hepatitis B infection (HBsAg clearance) was difficult to attain with such treatments. Therefore, new treatment strategies or innovative treatments are urgently needed. The new treatments should focus on the potential therapeutic targets such as covalently closed circular DNA which may be important for the HBsAg clearance. Plant based medicines have been used in different traditional medicine practices and these natural products/compounds serve as a good source of information or clues for use in drug discovery and design. Many natural products were found to be effective against hepatitis B virus and some even have better therapeutic activities than currently used compounds. This review summarizes the current evidence of Myanmar medicinal plants in basic and clinical research which shows promising potential for the development of novel therapeutic agents for the treatment of hepatitis B.

Chemical Composition, Pharmacological, and Toxicological Effects of Betel Nut

Betel nut, the fruit of Areca catechu L, has a long medical history in Southeast Asia. It is native to Malaysia and is cultivated and processed extensively in subtropical regions, such as South China and India. Betel nut almost appears as a "snack" in various occasions in most parts of China. Clinically, betel nut can play a certain pharmacology role and was used in malaria, ascariasis, arthritis, enterozoic abdominalgia, stagnation of food, diarrhea, edema, and beriberi. The nervous excitement of betel nut chewing has made it gradually become popular. However, chewing betel nut can induce oral submucosal fibrosis (OSF) and oral cancer (OC). At the same time, long-term chewing of betel nut also causes inhaled asthma, sperm reducing, betel quid dependence (BQD), and uterine and esophageal cancers. The main components of processed betel nut are the goal of this review. This study will mainly start from the pharmacological activity and toxicology study of betel nut in recent years, aiming to seek its advantages and disadvantages. In the meantime, this study will analyze and emphasize that betel nut and arecoline are the high-risk factors for oral cancer, which should arouse attention and vigilance of the public.

Serum aflatoxin B1 antibody titer, percent hemolysis and transaminases in oral submucous fibrosis

Introduction

Areca nut is deeply rooted sociocultural habit in India. Areca nut reported to be infested by fungi during the field and storage conditions. Areca nut alkaloids, nitrosamines, tobacco and aflatoxin are cytotoxic, immunotoxic to red blood cell and epithelial cell. Hence, the present study was conducted to assess the serum aflatoxin B₁ (AFB₁) antibody titer, percent hemolysis and transaminases in oral submucous fibrosis (OSMF) patients.

Materials and Methods

In this study, 128 participants of which 88 were suffering from OSMF. Twenty participants were areca nut habitual without OSMF (habitual control) and 20 participants without any habit (healthy control). For the detection of AFB₁ antibody titer, AFB₁ antigen (Sigma) A6636 from Aspergillus flavus was used. Percent hemolysis was estimated as per the procedure described by Mathuria and Verma. Serum Glutamic oxalo acetic transaminase (SGOT) and Serum Glutamic pyruvic transaminase (SGPT) were estimated by the optimized ultraviolet method using the enzyme-linked immunosorbent assay kit.

Results

Mean SGOT, SGPT, percent hemolysis and AFB₁ antibody titer were significantly higher in participants with OSMF than the habitual and healthy controls. AFB₁ antibody titer and % hemolysis in both OSMF and habitual without OSMF were showed significant correlation, i.e., increased AFB₁ antibody titer with increased % hemolysis.

Conclusions

A study result demonstrates that aflatoxin causes increase in serum transaminases which is indicative of liver damage in OSMF. The combined toxic effects of areca nut alkaloids, tobacco and AFB₁ on red blood cell (RBC) cell wall might be responsible for increased percent hemolysis in OSMF and habitual control.

A Positive Relationship between Betel Nut Chewing and Significant Liver Fibrosis in NAFLD Subjects, but Not in Non-NAFLD Ones

Background: Betel nut chewing is associated with oral cancer, cardiovascular disease, liver cirrhosis, and hepatocellular carcinoma (HCC). The aim of this study was to explore the association of betel nut chewing with liver fibrosis in subjects with and without nonalcoholic fatty liver disease (NAFLD). Method: A total of 5967 subjects were enrolled. NAFLD was diagnosed with ultrasonography. Betel nut chewing was classified into non-chewing, ex-chewing, and current chewing, and cumulative dosages were calculated. The aspartate aminotransferase (AST)/platelet ratio index and NAFLD fibrosis scores (NFS) were calculated for evaluation of liver fibrosis. Results: NAFLD increased the associated risk of liver fibrosis in those with (odds ratio (OR): 5.51, 95% confidence interval (CI): 3.09–9.80) and without betel nut chewing (OR: 2.33, 95% CI: 1.64–3.29). In subjects without NAFLD, betel nut chewing was not associated with liver fibrosis (OR: 1.12, 95% CI: 0.44–2.86). In subjects with NAFLD, cumulative betel nut chewing and ex- and current chewing were positively associated with NFS and significant liver fibrosis. Conclusions: In subjects with NAFLD, betel nut chewing, even ex-chewing, was associated with a higher risk of liver fibrosis, where higher cumulative levels were found to increase the risk of significant liver fibrosis. However, the associated risk of liver fibrosis due to betel nut chewing was insignificant in subjects without NAFLD.

Vildagliptin, a dipeptidyl peptidase-4 inhibitor, reduces betel-nut induced carcinogenesis in female mice

AIM

Betel-nut, a popular masticatory among Southeast Asian populations is a class I carcinogen, previously associated with dyslipidemia and aberrant lipid metabolism, and is reported to be used more frequently by females, than males. This study investigates the potential of repurposing the anti-diabetic drug, vildagliptin, a dipeptidyl peptidase-4 inhibitor, for alleviating the oncogenic condition in female Swiss Albino mice administered an aqueous extract of betel-nut (AEBN) orally (2 mg ml^-1) for 24 weeks.

MAIN METHODS

Tissues were investigated by histopathological, immunohistochemical and apoptosis assays. Biochemical analyses of oxidative stress markers and lipid profile were performed using different tissues and sera. The expressions of different proteins involved in lipid metabolism and oncogenic pathways were evaluated by Western blotting.

KEY FINDINGS

AEBN induced carcinogenesis primarily in the liver by significantly impairing AMPK signaling, inducing oxidative stress, activating Akt/mTOR signaling, increasing Ki-67 immunoreactivity and cyclin D1 expression, and significantly diminishing apoptosis. Co-administration of AEBN with vildagliptin (10 mg kg^-1 body weight) for 8 weeks reduced liver dysplasia, and significantly decreased free palmitic acid, increased free oleic acid, normalized lipid profile, decreased oxidative stress, cyclin D1 expression, Ki-67 immunoreactivity, and Bcl2 expression, and increased the ratio of apoptotic/non-apoptotic cells. Mechanistically, vildagliptin elicited these physiological and molecular alterations by restoring normal AMPK signaling and reducing the cellular expressions of FASN and HMGCR, restoring AMPK-dependent phosphorylation of p53 at Ser-15 and reducing Akt/mTOR signaling.

SIGNIFICANCE

These results indicate that vildagliptin may alleviate betel-nut induced carcinogenesis in the liver of female mice.

Downregulation of the DNA Repair Gene DDB2 by Arecoline Is through p53's DNA-Binding Domain and Is Correlated with Poor Outcome of Head and Neck Cancer Patients with Betel Quid Consumption

Arecoline is the principal alkaloid in the areca nut, a component of betel quids (BQs), which are carcinogenic to humans. Epidemiological studies indicate that BQ-chewing contributes to the occurrence of head and neck cancer (HNC). Previously, we have reported that arecoline (0.3 mM) is able to inhibit DNA repair in a p53-dependent pathway, but the underlying mechanism is unclear. Here we demonstrated that arecoline suppressed the expression of DDB2, which is transcriptionally regulated by p53 and is required for nucleotide excision repair (NER). Ectopic expression of DDB2 restored NER activity in arecoline-treated cells, suggesting that DDB2 downregulation was critical for arecoline-mediated NER inhibition. Mechanistically, arecoline inhibited p53-induced DDB2 promoter activity through the DNA-binding but not the transactivation domain of p53. Both NER and DDB2 promoter activities declined in the chronic arecoline-exposed cells, which were consistent with the downregulated DDB2 mRNA in BQ-associated HNC specimens, but not in those of The Cancer Genome Atlas (TCGA) cohort (no BQ exposure). Lower DDB2 mRNA expression was correlated with a poor outcome in HNC patients. These data uncover one of mechanisms underlying arecoline-mediated carcinogenicity through inhibiting p53-regulated DDB2 expression and DNA repair.

A comparison for the effects of raw, smoked, and smoked and brined areca nut extracts on the immune and inflammatory responses in the Kunming mice

Chewing of areca nuts is quite popular in various regions worldwide. Previous studies have demonstrated the pharmacological and toxicological effects of fresh areca nuts. However, processed areca nuts, which are popular in the Hunan province of China, have not been extensively studied for its biological effect. This study aimed at investigating the impact of the acrea nut extracts (ANE) prepared from the raw material, the semi-product, and the final product on the immune system and inflammation-related markers in the Kunming mice. The mice were assigned to seven different groups and administered different ANE at two concentrations (1X and 5X) for four weeks. Total body weight gain and organ coefficient of the liver, spleen, and kidney, as well as the immune system and inflammation-related markers were evaluated. The results revealed that processed areca nuts have a much milder effect on the mice immune system and some inflammatory markers than fresh areca nut in the Kunming mice. PRACTICAL APPLICATIONS: Chewing various forms of areca nuts is popular in China, Southeast Asia, and other regions. People from Hunan, China prefer to chew a processed areca nut, which has rarely been studied. This manuscript explores the effects of three kinds of areca nut extracts on the immune system- and inflammation-related indicators in Kunming mice. The obtained results revealed that processed areca nuts had significantly milder effects than the raw nut/nut extract, particularly on the body weight, immune responses, and inflammatory markers. The results of the present study provide some new directions for the areca nut industry and raise public awareness for the undesirable effects of areca nuts.

Assessment of risk factors, and racial and ethnic differences in hepatocellular carcinoma

Despite improved screening and surveillance guidelines, significant race/ethnicity‐specific disparities in hepatocellular carcinoma (HCC) continue to exist and disproportionately affect minority and disadvantaged populations. This trend indicates that social determinants, genetic, and environmental factors are driving the epidemic at the population level. Race and geography had independent associations with risk of mortality among patients with HCC. The present review discusses the risk factors and issues related to disparities in HCC. The underlying etiologies for these disparities are complex and multifactorial. Some of the risk factors for developing HCC include hepatitis B (HBV) and hepatitis C (HCV) viral infection, nonalcoholic fatty liver disease, nonalcoholic steatohepatitis, smoking and alcohol consumption. In addition, population genetics; socioeconomic and health care access; treatment and prevention differences; and genetic, behavioral, and biological influences can contribute to HCC. Acculturation of ethnic minorities, insurance status, and access to health care may further contribute to the observed disparities in HCC. By increasing awareness, better modalities for screening and surveillance, improving access to health care, and adapting targeted preventive and therapeutic interventions, disparities in HCC outcomes can be reduced or eliminated.

Areca catechu-From farm to food and biomedical applications

The family Arecaceae includes 181 genera and 2,600 species with a high diversity in physical characteristics. Areca plants, commonly palms, which are able to grow in nearly every type of habitat, prefer tropical and subtropical climates. The most studied species Areca catechu L. contains phytochemicals as phenolics and alkaloids with biological properties. The phenolics are mainly distributed in roots followed by fresh unripe fruits, leaves, spikes, and veins, while the contents of alkaloids are in the order of roots, fresh unripe fruits, spikes, leaves, and veins. This species has been reputed to provide health effects on the cardiovascular, respiratory, nervous, metabolic, gastrointestinal, and reproductive systems. However, in many developing countries, quid from this species has been associated with side effects, which include the destruction of the teeth, impairment of oral hygiene, bronchial asthma, or oral cancer. Despite these side effects, which are also mentioned in this work, the present review collects the main results of biological properties of the phytochemicals in A. catechu. This study emphasizes the in vitro and in vivo antioxidant, antimicrobial, anticancer, and clinical effectiveness in humans. In this sense, A. catechu have demonstrated effectiveness in several reports through in vitro and in vivo experiments on disorders such as antimicrobial, antioxidant, or anticancer. Moreover, our findings demonstrate that this species presents clinical effectiveness on neurological disorders. Hence, A. catechu extracts could be used as a bioactive ingredient for functional food, nutraceuticals, or cosmeceuticals. However, further studies, especially extensive and comprehensive clinical trials, are recommended for the use of Areca in the treatment of diseases.

Treatment with the anti-diabetic drug metformin ameliorates betel-nut induced carcinogenesis in a murine model

BACKGROUND

Metformin, a widely used anti-diabetic drug has gained enormous attention as an anticancer agent. This study seeks to investigate the efficacy of metformin in ameliorating aqueous extract of betel-nut (AEBN) and arecoline induced carcinogenesis in a murine model.

METHODS

Swiss albino mice were exposed to AEBN (2 mg ml-1) and arecoline (10 μg ml-1) in drinking water for 16 weeks followed by co-administration of metformin (75 mg kg-1 or 150 mg kg-1) for 4 or 8 weeks. Histological changes and oxidative stress were assessed by haematoxylin and eosin staining, TBARS assay and protein carbonylation assay respectively. Lipid profile was determined using an automated analyzer. Expression of total and phosphorylated AMPK, ACC and p53 were determined by immunoblotting.

RESULTS

AEBN and arecoline induced dyslipidemia by downregulating AMPK (Thr-172) and activating ACC (Ser-79); they also downregulated tumor suppressor p53 (Ser-15). Metformin treatment induced AMPK-dependent alleviation of dyslipidemia in a dose and time dependent manner, upregulated p53 (Ser-15), restored tissue architecture and reduced oxidative stress in tissues of AEBN and arecoline treated mice.

CONCLUSION

This study establishes that betel nut induces dyslipidemia through its alkaloid, arecoline by inhibition of AMPK (Thr-172) and activation of ACC (Ser-79) and highlights the therapeutic potential of metformin for treatment of betel-nut induced carcinogenesis, indicating the repurposing of the old drug in a new avenue.

Association between Parkinson's Disease and Risk of Cancer: A PRISMA-compliant Meta-analysis

Previous studies exploring associations between Parkinson's disease (PD) and cancer risks provided controversial results. We conducted this study to examine the association between PD and cancer risks among different cancer types in worldwide populations. We searched for articles published before August 2019 in databases PubMed, Web of Science, EMBASE, Medline, and Google Scholar. The multivariate odds ratio (OR)/relative risk (RR) and 95% confidence intervals (CI) were computed to explore associations between PD and risks of different types of cancers. The present study indicated significantly negative associations between PD and risks of all types of cancers, digestive system cancers, lung cancers, and urinary system cancers. Additionally, no significant associations were shown between PD and risks of breast cancers, reproductive system cancers, or hematological malignancies. The study showed significantly positive associations between PD and risks of skin cancers and brain cancers. In conclusion, our investigation showed that PD patients showed reduced overall cancer risk and reduced risk of some types of cancers (digestive system cancers, lung cancers, and urinary system cancers). We need further studies to explore the underlying mechanism of the association between PD and cancers.

DARK Classics in Chemical Neuroscience: Arecoline

Arecoline is a naturally occurring psychoactive alkaloid from areca (betel) nuts of the areca palm ( Areca catechu) endemic to South and Southeast Asia. A partial agonist of nicotinic and muscarinic acetylcholine receptors, arecoline evokes multiple effects on the central nervous system (CNS), including stimulation, alertness, elation, and anxiolysis. Like nicotine, arecoline also evokes addiction and withdrawal symptoms (upon discontinuation). The abuse of areca nuts is widespread, with over 600 million users globally. The importance of arecoline is further supported by its being the world's fourth most commonly used human psychoactive substance (after alcohol, nicotine, and caffeine). Here, we discuss neuropharmacology, pharmacokinetics, and metabolism of arecoline, as well as social and historical aspects of its use and abuse. Paralleling clinical findings, we also evaluate its effects in animal models and outline future clinical and preclinical CNS research in this field.

Effects of oral hygiene programme and home phone counselling for hepatitis C patients receiving antiviral treatment

AIMS

To explore the effectiveness of an oral hygiene programme combined with home phone counselling on hepatitis C patients during antiviral treatment.

BACKGROUND

Hepatitis C virus infection is the leading cause of liver diseases. Evidence indicates that the antiviral treatment for hepatitis C virus infection has been successful, albeit its many side effects, such as discomfort symptoms of oral ulcers, which, in turn, leads to discontinued treatment. Inappropriate oral hygiene may worsen the side effects and increase the risk of dropping out of the treatment.

DESIGN

A quasi-experimental pre-post-test design was used.

METHODS

The oral hygiene programme was based on a standardized protocol of oral health care combined with home phone counselling. The participants were recruited from an outpatient clinic between August 2016 and July 2017. The generalized estimating equation was used for repeated measures of oral health behaviour, oral health status and discomfort symptoms.

FINDINGS

Thirty-four participants completed this study. The findings indicated that the oral hygiene programme significantly improved tooth brushing, use of dental floss and oral comfort. The result showed that the participants' oral health status significantly improved in 3 months.

CONCLUSIONS

This pilot study supports the finding that an oral hygiene programme can reduce oral discomfort, improve oral hygiene behaviour, and enhance the oral health status of hepatitis C patients receiving treatment. This is a simple and low-cost programme, which can be performed at home easily and boosts the completion of antiviral treatment.

CYP450-mediated mitochondrial ROS production involved in arecoline N-oxide-induced oxidative damage in liver cell lines

BACKGROUND

IARC has classified the betel nut as a human environmental carcinogen. Previous studies have found that arecoline (AR) is the major alkaloid present in the saliva of betel quid chewers. Saliva contains a large content of AR which has been further shown to cause mutation of oral mucosa cells, resulting in oral cancer. Whereas, to date, there are only few studies reported the hepatotoxicity associated with arecoline and betel nut chewing. Therefore, the main purpose of this study was to determine the toxic effects of AR and its oxidative metabolite, arecoline N-oxide (ARNO), in normal liver cell lines.

METHODS

The cytotoxic, genotoxic, and mutagenic effects were detected by crystal violet staining, alkaline comet assay, and Salmonella mutagenicity test, respectively. Measurement of intracellular reactive oxygen species (ROS) generation was determined using the H2-DCFDA assay.

RESULTS

Our results demonstrated that ARNO exerted higher cytotoxicity, DNA damage, and mutagenicity than its parent compound arecoline in liver cells. Antioxidants, such as N-acetylcysteine, Trolox, and penicillamine, strongly protected liver cells from ARNO-induced DNA damage and ROS production. Furthermore, co-treatment with Mito-TEMPO also effectively blocked ARNO-induced ROS production in liver cells. Besides antioxidants, co-treatment with 1-aminobenzotriazole and methimazole nearly completely suppressed ARNO-induced ROS production in liver cells.

CONCLUSIONS

Our data suggest that arecoline ingested from the habit of chewing betel quid can be primarily oxidized to ARNO, thereby enhancing its toxicity through increased ROS production. Considering the excellent protective effects of both mitochondria-targeted antioxidant and CYP450 inhibitor on ARNO-induced ROS production in liver cells, mitochondria CYP450-mediated metabolism of ARNO may be a key mechanism. Collectively, our results provide novel cellular evidence for the positive connection between habitual betel quid chewing and the risk for liver damage.

Update in global trends and aetiology of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver responsible for an increasing number of cancer-related deaths, especially in developing economies of Asia and Africa. A plethora of risk factors have been described in the literature. Some of the important ones include chronic viral hepatitis, liver cirrhosis, environmental toxins such as aflatoxin, non-alcoholic fatty liver disease, lifestyle factors like alcohol consumption, smoking, and dietary factors, metabolic diseases like diabetes mellitus and obesity, and genetic and hereditary disorders. The development of HCC is complex involving sustained inflammatory damage leading to hepatocyte necrosis, regeneration, and fibrotic deposition. It also poses multiple challenges in diagnosis and treatment despite advances in diagnostic, surgical, and other therapeutic advancements. This is a narrative review of findings of multiple studies that were retrieved from electronic databases like PubMed, MEDLINE, Embase, Google Scholar, Scopus, and Cochrane. We summarise the current knowledge regarding the epidemiology and various risk factors for the development of HCC with a brief note on various prevention strategies.

Betel Chewing and Nonalcoholic Steatohepatitis

Betel chewing is a common social practice in many regions of the world particularly in Southeast Asia and among the Asian immigrant populations in the West. Several studies have shown betel chewing to be associated with increased risk for various health complications including liver cirrhosis and hepatocellular carcinoma. The exact mechanism by which betel causes liver damage has not been elucidated. We present a 31-year-old Asian immigrant in the United States of America (USA) with no family history of the liver disease and non-smoker who was found to have an unexplained persistent mild elevation of liver transaminases. She reported more than 16 kilograms of weight gain over an eight-year period in association with heavy betel chewing. Despite diet and exercise, she was not able to lose weight. Besides, she developed dyslipidemia and gradual worsening of glucose tolerance. Liver biopsy showed severe steatosis with features of nonalcoholic steatohepatitis (NASH). The gradual development and worsening of metabolic syndrome and NASH paralleling betel use are very indicative of the hepatic steatosis being caused by betel.

Tobacco-Smoking, Alcohol-Drinking, and Betel-Quid-Chewing Behaviors: Development and Use of a Web-Based Survey System

Background

Smoking tobacco, drinking alcohol, and chewing betel quid are health-risk behaviors for several diseases, such as cancer, cardiovascular disease, and diabetes, with severe impacts on health. However, health care providers often have limited time to assess clients’ behaviors regarding smoking tobacco, drinking alcohol, and chewing betel quid and intervene, if needed.

Objective

The objective of this study was to develop a Web-based survey system; determine the rates of tobacco-smoking, alcohol-drinking, and betel-quid-chewing behaviors; and estimate the efficiency of the system (time to complete the survey).

Methods

Patients and their family members or friends were recruited from gastrointestinal medical–surgical, otolaryngology, orthopedics, and rehabilitation clinics or wards at a medical center in northern Taiwan. Data for this descriptive, cross-sectional study were extracted from a large series of research studies. A Web-based survey system was developed using a Linux, Apache, MySQL, PHP stack solution. The Web survey was set up to include four questionnaires: the Chinese-version Fagerstrom Tolerance Questionnaire, the Chinese-version Alcohol Use Disorders Identification Test, the Betel Nut Dependency Scale, and a sociodemographic form with several chronic diseases. After the participants completed the survey, the system automatically calculated their score, categorized their risk level for each behavior, and immediately presented and explained their results. The system also recorded the time each participant took to complete the survey.

Results

Of 782 patient participants, 29.6% were addicted to nicotine, 13.3% were hazardous, harmful, or dependent alcohol drinkers, and 1.5% were dependent on chewing betel quid. Of 425 family or friend participants, 19.8% were addicted to nicotine, 5.6% were hazardous, harmful, or dependent alcohol drinkers, and 0.9% were dependent on chewing betel quid. Regarding the mean time to complete the survey, patients took 7.9 minutes (SD 3.0; range 3-20) and family members or friends took 7.7 minutes (SD 2.8; range 3-18). Most of the participants completed the survey within 5-10 minutes.

Conclusions

The Web-based survey was easy to self-administer. Health care providers can use this Web-based survey system to save time in assessing these risk behaviors in clinical settings. All smokers had mild-to-severe nicotine addiction, and 5.6%-12.3% of patients and their family members or friends were at risk of alcohol dependence. Considering that these three behaviors, particularly in combination, dramatically increase the risk of esophageal cancer, appropriate and convenient interventions are necessary for preserving public health in Taiwan.

Sub-chronic toxicity study of arecae semen aqueous extract in Wistar rats

ETHNOPHARMACOLOGICAL RELEVANCE

Arecae semen, the ripe seed of Areca catechu L., has been used as vermifuge and digestant in traditional Chinese medicine (TCM). However, the potential toxicity effect of arecae semen has not been completely investigated.

THE AIM OF THE STUDY

The present study was aimed at evaluating the sub-chronic toxicity of arecae semen by oral administration in Wistar rats.

MATERIALS AND METHODS

A total of 120 Wistar rats were randomly divided into 4 groups (15 males and 15 females per group). The treated groups were given arecae semen aqueous extract (ASAE) at the dose of 750, 1500 and 4500mg/kg/day by oral administration respectively, and the control group was received distilled water only. The rats and their consumed feed were weighted every 3 days. The clinical changes and mortality were observed and recorded daily. Hematological parameters, biochemical parameters, organ weights, urinalysis and histopathological examination of all rats were tested at the end of the 30-day treatment period and another 10-day recovery period.

RESULTS

Deaths, weight loss, diarrhea, sluggish action, tremors and body curl up were observed in the 1500 and 4500mg/kg groups during the study. The relative organ weights of liver and testis in male rats of 4500mg/kg group were significantly different compared with the control group at the end of the treatment period. As for laboratory parameters, there were no significant differences at the dose of 1500 and 4500mg/kg groups compared with the control group in the study, except the white blood cell count (WBC), aspartate aminotransferase (AST), alanine aminotransferase (ALT), albumin (ALB), blood urea nitrogen (BUN), creatinine (Cr), glucose (GLU) and total cholesterol (CHOL). In addition, the results of histopathological examination and feed intake showed no significant difference compared with the control group.

CONCLUSIONS

The results showed that ASAE at the dose of 750mg/kg/day was safe, but long-term oral administration of ASAE with high dosage was toxic. Moreover, the toxic ingredients of ASAE including arecoline, and also some other compounds should be researched.

Areca nut chewing is associated with common mental disorders: a population-based study

INTRODUCTION

Forms of habitual substance use including cigarette smoking and alcohol consumption have been documented as risk factors of common mental disorders (CMDs). The effects of areca nut chewing on biophysiological tests, metabolic syndromes, and liver function have been reported previously; however, the relationship between areca nut chewing and CMDs remains unclear. This study examined the association between areca nut chewing and CMDs and explored the relationships between areca nut chewing and biophysiological indicators.

METHODS

A total of 4477 community dwellers who had enrolled in a cohort study and participated in health examinations in 2 consecutive years were selected for analysis in the present study. The community cohort was established in northern Taiwan during 2006-2012. The Chinese health questionnaire (CHQ-12) was used as a self-reported screening instrument to assess the potential for developing psychotic mental disorders (CHQ-12 score ≥ 3) among the community residents. Biophysiological tests performed 1 year before CMD assessment were analyzed to examine the causal pathways between areca nut chewing and CMDs. Multiple logistic regression and stratified analyses were performed.

RESULTS

A total of 18.23% of the participants were diagnosed as having CMDs. Factors including areca nut chewing [odds ratio (OR) 1.828; 95% confidence interval (CI) 1.165-2.869], sex (women; OR 1.828; 95% CI 1.165-2.869), age (30-49; OR 1.302; 95% CI 1.073-1.579), and socioeconomic status (lower status; OR 1.373; 95% CI 1.084-1.738) were associated with CMDs in a multiple logistic regression model. Areca nut chewers exhibited significantly more triglycerides (220.04 vs. 124.16 mg/dL) and white blood cells (65.17 102/μL vs. 60.36 102/μL) and significantly higher diastolic blood pressure (78.83 vs. 75.84 mmHg) and glutamic oxaloacetic transaminase (30.30 vs. 25.45 U/L) than did the controls.

CONCLUSIONS

This study demonstrated the association between areca nut chewing and CMDs and its effects on biophysiological tests in a community-based population in Taiwan. The findings suggest the existence of mechanistic effects of areca nut chewing on CMDs exerted through multiple pathways that may interact with pre-existing biophysiological abnormalities. Lifestyle variables should be considered for the prevention and management of mental disorders in the future.

The risk of cirrhosis in non-alcohol drinkers is greater in female than male betel nut chewers

Background and Aim

The association of betel nut with liver cirrhosis among alcohol drinkers has been clearly shown. However, very few studies have shown such an association among non-alcohol drinkers. The aim of this study was to assess the relationship between betel nut chewing and cirrhosis among non-alcohol drinkers.

Materials and Methods

This study retrospectively analyzed data retrieved from the 2012 Adult Preventive Medical Services and the National Health Insurance Research Datasets in Taiwan. Participants’ information included physical examination and lifestyle, alongside laboratory tests. Betel nut chewers were grouped into three categories: never, occasional and frequent. Diseases were diagnosed using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Initially, 1573024 adults aged 40 years and above who engaged in the free adult preventive medical services in 2012 were recruited. However, only 1065246 of them were included in the analysis. Chi-square test and logistic regression were used for the analyses.

Results

After multivariable adjustments, there were significant relationships between cirrhosis and betel nut chewing in both sexes (P-trend < 0.0001). The risk of cirrhosis was greater in females than males. The odds ratios of cirrhosis in occasional and frequent female chewers were respectively 2.91; 95% C.I: 1.75–4.83 and 3.06; 95% C.I: 1.69–5. However, they were respectively 1.76; 95% C.I: 1.47–2.10 and 2.32; 95% C.I: 1.90–2.85 in occasional and frequent male chewers.

Conclusions

This study demonstrated significant relationships between betel nut chewing and cirrhosis in both male and female non-alcohol drinkers. The risk of cirrhosis was greater in female than male chewers.

Cancer in Guam and Hawaii: A comparison of two U.S. Island populations

BACKGROUND

Cancer disparities within and across populations provide insight into the influence of lifestyle, environment, and genetic factors on cancer risk.

METHODS

Guam cancer incidence and mortality were compared to that of Hawaii using data from their respective population-based, central cancer registries.

RESULTS

In 2009-2013, overall cancer incidence was substantially lower in Guam than in Hawaii for both sexes while overall cancer mortality was higher for Guam males. Cervical cancer incidence and prostate cancer mortality were higher in Guam. Both incidence and mortality were higher among Guam men for cancers of the lung & bronchus, liver & intrahepatic bile duct, and nasopharynx; Chamorro men were disproportionately affected by these cancers. Filipinos and Whites in Guam had lower overall cancer incidence compared to Filipinos and Whites in Hawaii. Although breast cancer incidence was significantly lower in Guam compared to Hawaii, women in Guam presented at younger ages and with rarer disease histologies such as inflammatory carcinoma were more prevalent. Guam patients were also diagnosed at younger ages for cancers of bladder, pancreas, colon & rectum, liver & intrahepatic bile duct, lung & bronchus, stomach, non-Hodgkin lymphoma, and leukemia.

CONCLUSION

Smoking, infectious agents, and betel nut chewing appear to be important contributors to the burden of cancer in Guam. Earlier onset of cancer in Guam suggests earlier age of exposure to key risk factors and/or a more aggressive pathogenesis. Contrasting cancer patterns within Guam and between Guam and Hawaii underscore the potential influence of genes, lifestyle, and environmental factors on cancer development and progression.

Cost-effectiveness analysis of population-based screening of hepatocellular carcinoma: Comparing ultrasonography with two-stage screening

AIM: To assess the cost-effectiveness of two population-based hepatocellular carcinoma (HCC) screening programs, two-stage biomarker-ultrasound method and mass screening using abdominal ultrasonography (AUS).

METHODS: In this study, we applied a Markov decision model with a societal perspective and a lifetime horizon for the general population-based cohorts in an area with high HCC incidence, such as Taiwan. The accuracy of biomarkers and ultrasonography was estimated from published meta-analyses. The costs of surveillance, diagnosis, and treatment were based on a combination of published literature, Medicare payments, and medical expenditure at the National Taiwan University Hospital. The main outcome measure was cost per life-year gained with a 3% annual discount rate.

RESULTS: The results show that the mass screening using AUS was associated with an incremental cost-effectiveness ratio of USD39825 per life-year gained, whereas two-stage screening was associated with an incremental cost-effectiveness ratio of USD49733 per life-year gained, as compared with no screening. Screening programs with an initial screening age of 50 years old and biennial screening interval were the most cost-effective. These findings were sensitive to the costs of screening tools and the specificity of biomarker screening.

CONCLUSION: Mass screening using AUS is more cost effective than two-stage biomarker-ultrasound screening. The most optimal strategy is an initial screening age at 50 years old with a 2-year inter-screening interval.

Association between betel quid chewing and carotid intima-media thickness in rural Bangladesh

BACKGROUND

Areca nut, more commonly known as betel nut, is the fourth most commonly used addictive substance in the world. Though recent evidence suggests it may play a role in the development of cardiovascular disease, no studies have investigated whether betel nut use is related to subclinical atherosclerosis.

METHODS

We evaluated the association between betel nut use and subclinical atherosclerosis in 1206 participants randomly sampled from the Health Effects of Arsenic Longitudinal Study (HEALS). Frequency and duration of betel nut use were assessed at baseline, and carotid IMT was measured on average 6.65 years after baseline.

RESULTS

A positive association was observed between duration and cumulative exposure (function of duration and frequency) of betel nut use and IMT, with above-median use for duration (7 or more years) and cumulative exposure (30 or more quid-years) corresponding to a 19.1 μm [95% confidence interval (CI): 5.3-32.8; P ≤ 0.01] and 16.8 μm (95% CI: 2.9-30.8; P < 0.05) higher IMT in an adjusted model, respectively. This association was more pronounced in men [32.8 μm (95% CI: 10.0-55.7) and 30.9 μm (95% CI: 7.4-54.2)]. There was a synergy between cigarette smoking and above-median betel use such that the joint exposure was associated with a 42.4 μm (95% CI: 21.6-63.2; P ≤ 0.01) difference in IMT.

CONCLUSION

Betel nut use at long duration or high cumulative exposure levels is associated with subclinical atherosclerosis as manifested through carotid IMT. This effect is especially pronounced among men and cigarette smokers.

Discrepancy between serological and virological analysis of viral hepatitis in hemodialysis patients

BACKGROUND AND AIM

Viral hepatitis is a health threat for hemodialysis (HD) patients and it may be transmitted during treatment. Some patients categorized to have viral hepatitis were found to be non-viremic. To clarify the discrepancy between the serological tests in HD patients, we conducted the study.

METHODS

A total of 1681 HD patients was included. Blood samples were analyzed for hepatitis B surface antigen (HBsAg) and anti-hepatitis C antibody (anti-HCV). Detection of hepatitis B virus (HBV) DNA and hepatitis C virus (HCV) RNA were performed in either HBsAg (+) or anti-HCV (+) samples. HBV DNA/HCV RNA was also measured in a subset of HBsAg (-) and anti-HCV (-) patients. Liver function tests were analyzed and compared with the serological and virological tests.

RESULTS

The serological tests showed that 230 patients (13.7%) were HBsAg (+) and 290 (17.3%) were anti-HCV (+). We were unable to detect HBV DNA in 97 of 230 (42.2%) HBsAg (+) patients, and HCV RNA could not be found in 76 of 290 (26.2%) anti-HCV (+) patients. In 167 HBsAg (-) patients, only one showed a trace amount of HBV DNA. None of 151 anti-HCV (-) patients showed detectable HCV RNA. The prevalence rate of viral hepatitis remains high in Taiwanese HD patients: 13.7% for HBV and 17.3% for HCV. However, virological analysis showed 42.2% non-viremic rate for HBsAg and 26.2% non-viremic rate for anti-HCV.

CONCLUSIONS

The findings might challenge the presently suggested principles of bed and machine dedication and the diagnosis of viral hepatitis in HD patients.

Areca nut chewing and systemic inflammation: evidence of a common pathway for systemic diseases

Background

Areca nut, the seed of fruit of an oriental palm, known as Areca catechu, is commonly chewed in many countries. Diabetes, hypertension, cardiovascular diseases, oropharyngeal and oesophageal cancers have been associated with areca nut chewing and the mechanism by which areca nut chewing increases the risk of systemic diseases remains elusive. We hypothesize that systemic inflammation may be elevated among areca nut users, which is linked with many systemic diseases. Therefore, this present study was conducted to examine the systemic inflammation among areca nut chewers and healthy controls.

Methods

This was an observational cross sectional study carried out on areca nut chewers and healthy individuals in Karachi, Pakistan. Participants were selected from a region of the city by invitation request sent from door to door. Information was collected regarding the socio-demographic profile and the pattern of use, and a blood sample was obtained to measure the level of C-reactive protein (CRP). We carried out multiple logistic regressions to investigate the association between socio-demographic profile, areca nut chewing and CRP levels.

Results

We carried out final analysis on 1112 individuals of which 556 were areca nut chewers and 556 were the age, gender and area matched controls. Areca nut chewers had a significantly higher proportion of men (15.1%, n = 84) who had an elevated CRP (>10 mg/dl) as compared to controls (5.2%, n = 29). Multivariate analyses showed that areca nut chewers had significantly higher odds of an elevated CRP (OR = 3.23, 95% CI 2.08-5.02, p value <0.001) as compared to controls. Increase in amount of areca nut consumption had a significant dose–response relationship with systemic inflammation (p for trend <0.001). Further analysis revealed that areca nut chewers with tobacco additives were two times more likely to have an elevated CRP as compared to raw areca nut users. These associations remained unchanged after adjustments for age, BMI and years of full time education.

Conclusions

Areca nut chewing has a significant association with systemic inflammation. Further work is required to confirm that systemic inflammation is the main pathway by which areca nut use increases the risk of systemic diseases.

Predicting postoperative morbidity and mortality by model for endstage liver disease score for patients with head and neck cancer and liver cirrhosis

BACKGROUND

The purpose of this study was to evaluate the Model for Endstage Liver Disease (MELD) scoring system for predicting the morbidity and mortality of patients with head and neck cancer with liver cirrhosis undergoing tumor resection with microsurgical free-tissue transfer.

METHODS

Between January 2000 and December 2008, 3108 cases were retrospectively reviewed.

RESULTS

There were 59 men and 2 women enrolled in this study. Preoperatively, 31 and 30 patients were classified as having lower (<9.73) and higher (>9.73) MELD scores, respectively. Patients with higher MELD scores had significantly more postoperative medical morbidities including pulmonary complications and gastrointestinal bleeding. The mortality rate was also significantly higher for higher MELD scorers (23.3% vs 3.2%; p = 0.026). By logistic regression model, preoperative MELD score was a significant predictive factor for morbidity and mortality in multivariate analysis.

CONCLUSION

MELD score could be used to predict morbidity and mortality for patients with head and neck cancer with liver cirrhosis undergoing tumor resection with microsurgical free tissue transfer.

Secondary prevention of esophageal squamous cell carcinoma in areas where smoking, alcohol, and betel quid chewing are prevalent

Esophageal cancer is ranked as the sixth most common cause of cancer death worldwide and has a substantial effect on public health. In contrast to adenocarcinoma arising from Barrett's esophagus in Western countries, the major disease phenotype in the Asia-Pacific region is esophageal squamous cell carcinoma which is attributed to the prevalence of smoking, alcohol, and betel quid chewing. Despite a multidisciplinary approach to treating esophageal cancer, the outcome remains poor. Moreover, field cancerization reveals that esophageal squamous cell carcinoma is closely linked with the development of head and neck cancers that further sub-optimize the treatment of patients. Therefore, preventive strategies are of paramount importance to improve the prognosis of this dismal disease. Since obstacles exist for primary prevention via risk factor elimination, the current rationale for esophageal cancer prevention is to identify high-risk groups at earlier stages of the disease, and encourage them to get a confirmatory diagnosis, prompt treatment, and intensive surveillance for secondary prevention. Novel biomarkers for identifying specific at-risk populations are under extensive investigation. Advances in image-enhanced endoscopy do not just substantially improve our ability to identify small precancerous or cancerous foci, but can also accurately predict their invasiveness. Research input from the basic sciences should be translated into preventive measures in order to decrease the disease burden of esophageal cancer.

Betel nut chewing and incidence of newly diagnosed type 2 diabetes mellitus in Taiwan

Background

Betel nut chewing is associated with type 2 diabetes mellitus (T2DM) in a recent prevalence study in Taiwan. The present study further investigated its link with the incidence of newly diagnosed T2DM during the years 1992-1996.

Methods

Population-based datasets of a sample of 93,484 out of 256,036 diabetic patients from 66 medical settings using the National Health Insurance scheme covering > 96% of the population, published population prevalence of betel nut chewing and the governmental census of national population were used for calculation of odds ratios, incidence rates and incidence rate ratios between chewers and never-chewers in the male population for the year 1992 to 1996.

Results

Ever chewers among the diabetic patients were younger, more obese and had higher prevalence of parental diabetes than never-chewers (all p values < 0.001). Odds ratios for T2DM for ever chewers vs. never-chewers in the age of < 40, 40-49, 50-59, 60-69 and ≥70 years were 1.06 (0.92-1.23), 1.60 (1.45-1.76), 2.12 (1.88-2.39), 3.58 (3.10-4.13) and 7.14 (5.47-9.31), respectively. In 1996, incidence rates (per 100,000 population) in the respective age groups were 19.1, 251.5, 567.3, 721.7 and 971.4 for never-chewers; and were 30.2, 520.9, 2566.9, 11672.8 and 630.3 for ever chewers. The respective incidence rate ratios were 1.58, 2.07, 4.52, 16.17 and 0.65. The age-specific incidence rates and rate ratios were relatively consistent from 1992 to 1996. The differences in obesity and parental diabetes between ever chewers and never-chewers were mostly not statistically significant after age stratification, suggesting the link could not be attributed to these two factors.

Conclusions

Chewing betel nut is associated with newly diagnosed T2DM, supporting the suggestion that the habit is diabetogenic.

Areca-nut extract modulates antigen-specific immunity and augments inflammation in ovalbumin-sensitized mice

Areca-nut chewing has been linked to oral cancer and many other diseases, in which immune deterioration and tissue inflammation are plausibly involved. Recent studies reported that areca-nut extract (ANE) affected the functionality of lymphocytes and neutrophils in vitro. In the present study, we investigated the immunomodulatory effect of ANE in vivo. Ovalbumin (OVA)-sensitized mice were daily administered with ANE (5-50 mg/kg) for 10 doses by intraperitoneal injection from days 1 to 5 and from 8 to 12. The mice were systemically sensitized with OVA on day 3, and their footpads were challenged with OVA to induce delayed-type hypersensitivity (DTH) reactions on day 13. The serum level of OVA-specific IgM and IgG(1) was significantly attenuated by 5 and 25 mg/kg of ANE, whereas OVA-specific IgG(2a) was markedly enhanced by 50 mg/kg of ANE. The production of interferon (IFN)-γ by splenocytes reexposed to OVA in culture was markedly augmented by ANE (25 and 50 mg/kg). In addition, ANE (25 and 50 mg/kg) demonstrated an enhancing effect on DTH reactions, including the tissue swelling, the infiltration of CD3(+) and F4/80(+) cells, and the expression of IFN-γ and tumor necrosis factor (TNF)-α in the footpads challenged with OVA. The phagocytic activity and TNF-α production by the splenic CD11b(+) cells were also enhanced in ANE-treated groups. Taken together, these results demonstrated that ANE modulated antigen-specific immune responses and promoted inflammatory reactions in vivo, which may contribute to immune deregulation associated with areca-related diseases.

Systemic conditions associated with areca nut usage: a literature review

AIM

The adverse effects of areca nut (AN) chewing habit on oral health have been reported. However, the hazards related to the habit are not restricted to the oral cavity but they can also jeopardise the systemic health. Since no review reporting the harmful effects of AN chewing on systemic health is yet available, the aim of the present study was to review the systemic conditions associated with AN usage.

METHODS

To address the focused question ''What are the deleterious effects of AN usage on systemic health?'', the MEDLINE PubMed databases were explored from 1966 up to and including May 2010. The eligibility criteria included: human studies, individuals using AN, use of controls, and articles published in English. Hand-searching was also performed. Unpublished data was excluded.

RESULTS

The review included 28 articles. Seven studies associated AN chewing with cardiovascular disorders and three studies related the habit with cerebrovascular disorders. Eight studies related AN chewing with obesity, hyperglycaemia, metabolic syndrome, and type 2 diabetes mellitus. Five studies related AN chewing with the development of hepatic disorders. Two studies associated the chewing habit with oesophageal inflammation and fibrosis. Three studies associated AN chewing with respiratory discomfort. Renal disorders were related with the chewing abuse in two studies. Two studies showed an adverse effect of AN chewing on birth outcome.

CONCLUSIONS

AN chewing adversely affects systemic health by damaging the vital organs.