Assessment of Registry-Based Surveillance Statistics Used for Cancer Control in the Dindigul District in South India

Background

Cancer incidence rates from the Dindigul district were lower by 50% than Chennai in Tamil Nadu for most cancers. This study describes the cancer surveillance statistics and provides an assessment of missing cases from routine registration in the Dindigul Ambilikkai Cancer Registry (DACR), covering a predominantly rural population in the Dindigul district.

Method

A total of 21,214 incident cancers in the DACR during 2003-2017 were examined for this study. Cancer registration was carried out by active case-finding following standard international norms. A total of 12,541 incident cancers registered during 2003-2012 and followed through 2014 were used to estimate survival. Data on follow-up were obtained through a mixture of active and passive methods. Survival probability was estimated by actuarial methods. A random survey carried out independently was used to assess the quality of case ascertainment.

Results

The age-standardized rate (ASR) per 100,000 population was higher among women (76.2) than men (61) in 2013-2017, with both sexes reporting a 17% increase compared to 2003-2007. The most common cancers were cervix (ASR,18.5) and female breast (ASR,17.1), with percentage changes of -19% and +46.1%, respectively. Lung cancer (ASR, 5.5) was top among men with an increasing trend (+57.1%). The percent change in ASR of mouth cancer showed opposite trends among men (+24.3%) and women (- 21.4%). The ASR of colorectal cancers almost doubled among men between 2003-2007 and 2013-2017 (3.9; +94.7%). The 5- and 10-year absolute survival for all cancers were 31% and 20%, respectively. Out of 365 incident cancers that occurred during 2003-2010 in the surveyed areas, 310 (84.9%) were already registered in the DACR, while 55 were newly identified from the survey (15.1%). Inadequate coverage of sources outside the Dindigul district was significant (P = .002), with the highest number of missed cases from hospitals under nongovernment sectors (58.3%). Underascertainment was higher among cancer patients living in hilly regions (60%) and border areas (47.4%) than in core regions (P = .05).

Conclusion

Because of an enacted government order making cancer a notifiable disease, the registry-based cancer surveillance could be extended, covering a population of 80 million in a cost-effective manner with enhanced coverage and systematic evaluation of cancer-screening programs.

One year outcomes of heart failure multispecialty multidisciplinary team virtual meetings

 

Heart Failure is frequently associated with several comorbidities such as ischaemic heard disease, diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease and frailty. This level of complexity is best dealt with by a multispecialty multidisciplinary team (MDT) model.

This was a single centre observational study (January 2020-December 2020) that was undertaken in a British university hospital looking at effect of HF multispecialty virtual MDT meetings on HF outcomes. Patients acted as their own controls outcomes compared for equal period pre versus post MDT meeting. The multi-specialty meeting was conducted once monthly via video-conferencing. It consisted of heart failure cardiologists (from primary secondary and tertiary care), heart failure specialist nurses (hospital and community), nephrologist, endocrinologist, palliative care specialists, chest physician, pharmacist, pharmacologist and geriatrician. Recommendations were made as consensus from the multispecialty meeting. The main outcome measures were 1) number of hospitalisations and 2) outpatient clinic attendances 3) cost savings.

A total of 189 patients were discussed from January-December 2020. This was uninterrupted during the COVID-19 pandemic. The mean age was 70.3±18.1 years and median follow-up 6 months (range 1–13 months). The mean Charlson Co-morbidity score was 5.3±1.2 and Rockwood Frailty Score was 4.9±1. The mean number of outpatient clinic attendances avoided was 1.7±0.4. This reduced inconvenience to patients, saved patients money (transport and parking costs) and led to carbon footprint reduction. The MDT meeting total costs were £15,400 and the 31 clinic appointments they generated cost an estimated £3720. However, the MDT meetings prevented 277 clinic appointments (cost saving £33,352). Finally, the mean number of hospitalisations pre-MDT was 0.7 Vs 0.2 post MDT (p<0.01) with a saving of around 730 bed days (estimated cost-saving £260,000).

The HF multispecialty virtual MDT approach provides seamless integration of primary care community services with secondary and tertiary care. Consensus decision from MDT meetings provides holistic approach for HF patients with comorbidities and frailty, and reduces inconvenience to patients by preventing the need to attend multiple specialty clinics. This approach can also lead to significant cost-savings to the healthcare system.

Funding Acknowledgement

Type of funding sources: None.

Cardiac rehabilitation and all-cause mortality in patients with heart failure: A retrospective cohort study

Funding Acknowledgements

Type of funding sources: None.

Background

Despite the benefits of exercise training in the secondary prevention of cardiovascular disease, there are conflicting findings for the impact of exercise-based cardiac rehabilitation (CR) on mortality for patients with heart failure (HF).

Methods

A retrospective cohort study was conducted which utilised a global federated health research network. Patients with a diagnosis of HF were compared between those with and without an electronic medical record of exercise-based CR within 6-months of a HF diagnosis. Patients with HF undergoing exercise-based CR were propensity score matched to HF patients without exercise-based CR by age, sex, race, co-morbidities, medications, and procedures. We ascertained 2-year incidence of all-cause mortality, hospitalisation, stroke, and atrial fibrillation.

Results

Following propensity score matching, a total of 40,364 patients with HF were identified. Exercise-based CR was associated with 42% lower odds of all-cause mortality (odds ratio 0.58, 95% confidence interval (CI): 0.54-0.62), 26% lower odds of hospitalisation (0.74, 95% CI 0.71-0.77), 37% lower odds of incident stroke (0.63, 95% CI 0.51-0.79), and 53% lower odds of incident atrial fibrillation (0.47, 95% CI 0.4-0.55) compared to matched controls. The beneficial association of exercise-based CR on all-cause mortality was consistent across stratification for sex, older age, included comorbidities, and HF subtype (all P < 0.0001), including patients with HFpEF (0.65, 95% CI 0.60-0.71).

Conclusions

Exercise-based CR was associated with lower odds of all-cause mortality, hospitalisations, incident stroke and incident atrial fibrillation at 2-years follow-up for patients with HF. The beneficial association of CR and lower mortality was consistent for patients with HFrEF and HFpEF.

Do Rockwood frailty score and Charlson comorbidity index help to risk stratify outpatient versus inpatient management of acute decompensated heart failure?

Introduction

Acute decompensated heart failure (ADHF) is associated with frailty and co-morbidities which influence prognosis. The Rockwood Frailty Score (RFS) and age-adjusted Charlson co-morbidity index (CCI) have been used to predict outcomes in hospitalised ADHF patients.

Purpose

To describe the relationship of CCI, RFS and clinical risk score -Get With The Guidelines Score (GWTG) with mortality in ADHF treated as outpatients (OP) versus hospitalised inpatients (IP).

Methods

This retrospective analysis compared 2 cohorts of consecutive ADHF patients - hospitalised in-patients (IP) versus outpatients (OP) who were treated with bolus intravenous diuretics in a specialist heart failure nurse delivered OP HF unit (Ambulatory HF Unit -AHFU) with input from various specialties (renal, palliative, ascitic, pleural teams) from Nov 16 to Dec 17. Mean follow-up duration was similar for both groups (IP=19.5±4.1 months; OP=19.3±3.9 months, p=0.6). Mortality was compared at 1, 3 and 12 months based on RFS (no frailty <5, mild to moderate frailty 5/6, severe frailty - 7 to 9). Results were expressed as mean±SD and analysed using One-Way ANOVA and Chi-squared with Fisher's exact test test.

Results

410 consecutive patients (482 admissions) were hospitalised (inpatients -IP) and 231 OP (289 OP visits) were treated in the AHFU. IP group had significantly higher mean CCI (IP=6.55±2; OP=6.10±1.9; p=0.006) and mean RFS (IP 5.2±1.2; OP 4.9±1.1; p=0.002). Mean Clinical Risk Score GWTG was similar (IP=38.9±7.2; OP=38.4±6.6; p=0.44). Mean survival was significantly lower in IP (IP=378±270 days; OP=437±228; P=0.003). As shown in the table higher RFS predicts increased mortality risk (1 month, 3 month and 12 month).

Conclusions

Rockwood Frailty Score predicts mortality in ADHF and assessment of RFS can play an important role in risk stratifying and decision-making in addition to clinical risk-scores, with regards to suitability for outpatient treatment of ADHF.

Funding Acknowledgement

Type of funding source: None

Prevalence and predictors of bacterial vaginosis in HIV-infected women in Maharashtra, India

We evaluated the prevalence and determinants of bacterial vaginosis (BV) in HIV-infected women from Maharashtra, India. Among 912 HIV-infected women enrolled, BV was diagnosed in 191 (20.9%) and intermediate BV was diagnosed in 258 (28.3%) women. Women with more than two pregnancies had 1.6 times increased risk of BV (95% CI 1.0, 2.5, p-value 0.038), women who were menopausal had 6.2 times increased risk of BV (95% CI 2.4, 15.6, p-value <0.001) and women who were human papillomavirus (HPV) positive had 2.3 times increased risk of BV (95% CI 1.4, 3.9, p-value 0.001). Although we observed significantly increased risk of BV among women diagnosed with cervical intraepithelial neoplasia or worse disease in the univariate analysis (odds ratio 3.5, 95% CI 1.5, 8.1, p-value 0.004), it did not reach statistical significance in the multivariate analysis. Women who had the first sexual intercourse after the age of 18 had significantly lower risk of BV. To conclude, we observed high prevalence of BV in HIV-infected women and increased risk of BV in HPV positive, HIV-infected women.

Deformation of dark solitons in a PT -invariant variable coefficients nonlocal nonlinear Schrödinger equation

We derive dark and antidark soliton solutions of a parity-time reversal (PT) -invariant variable coefficients nonlocal nonlinear Schrödinger (NNLS) equation. We map the considered equation into a defocusing PT -invariant NNLS equation with a constraint between dispersion, nonlinearity, and gain/loss parameters. We show that the considered system is PT -invariant only when the dispersion and nonlinearity coefficients are even functions and gain/loss coefficient is an odd function. The characteristics of the constructed dark soliton solutions are investigated with four different forms of dispersion parameters, namely, (1) constant, (2) periodically distributed, (3) exponentially distributed, and (4) periodically and exponentially distributed dispersion parameter. We analyze in detail how the nonlocal dark soliton profiles get deformed in the plane wave background with these dispersion parameters.

HPV vaccination of immunocompromised hosts

It is well-established that immunocompromised people are at increased risk of HPV-related disease compared with those who are immunocompetent. Prophylactic HPV sub-unit vaccines are safe and immunogenic in immunocompromised people and it is strongly recommended that vaccination occur according to national guidelines. When delivered to immunocompromised populations, HPV vaccines should be given as a 3-dose regimen.

Accuracy of conventional cytology: results from a multicentre screening study in India

Objective: We conducted a multi-centre cross-sectional study in India to evaluate the accuracy of conventional cytology to detect high-grade squamous intraepithelial lesions (HSIL).

Setting: Cross-sectional studies in Jaipur, Kolkata, Mumbai and Trivandrum, India, during 1999-2003.

Methods: A common protocol and questionnaire were used to test 22,663 women aged 25-65 years with conventional cytology in five cross-sectional studies. Three thresholds were used to define test positivity: atypical squamous cells of uncertain significance (ASCUS), low-grade squamous intra-epithelial lesion (LSIL), or HSIL. All screened women were investigated with colposcopy, and biopsies were taken when necessary. The reference standard for final disease status was histology or negative colposcopy. Data from the studies were pooled to evaluate the test characteristics for the detection of histologically confirmed HSIL.

Results: The test positivity rates of cytology were 8.8% at ASCUS, 6.2% at LSIL and 1.8% at HSIL thresholds, and 355 women had histologically confirmed HSIL while 74 had invasive cancer. The pooled sensitivity, specificity, positive and negative predictive values at ASCUS threshold were 64.5%, 92.3%, 11.8% and 99.4% respectively. The corresponding values at LSIL threshold were 58.0%, 94.9%, 15.2% and 99.3%, while at the HSIL threshold they were 45.4%, 99.2%, 46.3% and 99.1%. The sensitivity varied between 37.8-81.3% at ASCUS , 28.9-76.9% at LSIL and 24.4-72.3% at HSIL thresholds. A significantly low sensitivity was observed in women aged 25-39 years (p<0.001). The wide variation in sensitivity across study sites persisted even after age standardisation.

Conclusion: The sensitivity of cytology varied widely between the study sites. Findings from our study and other reviews indicate that sustained efforts in improving sampling, preparation and reading of cytological specimens and improvements in clinical judgement are essential to achieve concurrently high sensitivity and specificity.

Aminoacylation at the Atomic Level in Class IIa Aminoacyl-tRNA Synthetases

Abstract The crystal structures of histidyl- (HisRS) and threonyl-tRNA synthetase (ThrRS) from E. coli and glycyl-tRNA synthetase (GlyRS) from T. thermophilus, all homodimeric class IIa enzymes, were determined in enzyme-substrate and enzyme-product states corresponding to the two steps of aminoacylation. HisRS was complexed with the histidine analog histidinol plus ATP and with histidyl-adenylate, while GlyRS was complexed with ATP and with glycyl-adenylate; these complexes represent the enzyme-substrate and enzyme-product states of the first step of aminoacylation, i.e. the amino acid activation. In both enzymes the ligands occupy the substrate-binding pocket of the N-terminal active site domain, which contains the classical class II aminoacyl-tRNA synthetase fold. HisRS interacts in the same fashion with the histidine, adenosine and α-phosphate moieties of the substrates and intermediate, and GlyRS interacts in the same way with the adenosine and α-phosphate moieties in both states. In addition to the amino acid recognition, there is one key mechanistic difference between the two enzymes: HisRS uses an arginine whereas GlyRS employs a magnesium ion to catalyze the activation of the amino acid. ThrRS was complexed with its cognate tRNA and ATP, which represents the enzyme-substrate state of the second step of aminoacylation, i.e. the transfer of the amino acid to the 3'-terminal ribose of the tRNA. All three enzymes utilize class II conserved residues to interact with the adenosine-phosphate. ThrRS binds tRNA(Thr) so that the acceptor stem enters the active site pocket above the adenylate, with the 3'-terminal OH positioned to pick up the amino acid, and the anticodon loop interacts with the C-terminal domain whose fold is shared by all three enzymes. We can thus extend the principles of tRNA binding to the other two enzymes.

Using implementation science to advance cancer prevention in India

Oral, cervical and breast cancers, which are either preventable and/or amenable to early detection and treatment, are the leading causes of cancer-related morbidity and mortality in India. In this paper, we describe implementation science research priorities to catalyze the prevention and control of these cancers in India. Research priorities were organized using a framework based on the implementation science literature and the World Health Organization's definition of health systems. They addressed both community-level as well as health systems-level issues. Community-level or "pull" priorities included the need to identify effective strategies to raise public awareness and understanding of cancer prevention, monitor knowledge levels, and address fear and stigma. Health systems-level or "push" and "infrastructure" priorities included dissemination of evidence- based practices, testing of point-of-care technologies for screening and diagnosis, identification of appropriate service delivery and financing models, and assessment of strategies to enhance the health workforce. Given the extent of available evidence, it is critical that cancer prevention and treatment efforts in India are accelerated. Implementation science research can generate critical insights and evidence to inform this acceleration.

Recommendations for screening and early detection of common cancers in India

Cancers of the breast, uterine cervix, and lip or oral cavity are three of the most common malignancies in India. Together, they account for about 34% of more than 1 million individuals diagnosed with cancer in India each year. At each of these cancer sites, tumours are detectable at early stages when they are most likely to be cured with standard treatment protocols. Recognising the key role that effective early detection and screening programmes could have in reducing the cancer burden, the Indian Institute for Cytology and Preventive Oncology, in collaboration with the US National Cancer Institute Center for Global Health, held a workshop to summarise feasible options and relevant evidence for screening and early detection of common cancers in India. The evidence-based recommendations provided in this Review are intended to act as a guide for policy makers, clinicians, and public health practitioners who are developing and implementing strategies in cancer control for the three most common cancers in India.

The effect of 2,5-di-(tert-butyl)-1,4-benzohydroquinone (TBQ) on intracellular Ca2+ handling in rat ventricular myocytes

•

The suitability of TBQ as a specific inhibitor of SERCA was investigated.

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TBQ decreased SERCA activity in a concentration dependent manner.

•

TBQ inhibited the calcium current.

•

TBQ activated an outward current consistent with an ATP-dependent potassium channel.

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TBQ cannot be used as a specific inhibitor of SERCA in rat cardiac myocytes.

2,5-Di-(tert-butyl)-1,4-benzohydroquinone (TBQ) is a reversible inhibitor of SERCA, potentially making it a useful tool to study the effects of SERCA inhibition in cardiac cells. However, it is unknown if TBQ also has effects on other components of ventricular Ca handling. The aim of these experiments was to characterise the effects of TBQ on Ca handling in rat ventricular myocytes and assess its suitability as a specific inhibitor of SERCA. This was achieved by voltage clamp via perforated patch and [Ca²⁺]_i measurement using Fluo-3 AM. TBQ produced a fully reversible, concentration dependent decrease in the rate of systolic Ca decay. 10 μM TBQ decreased the amplitude of the systolic Ca transient by 48 ± 5% and the rate of decay by 54 ± 6%. SR Ca content was also reduced by 62 ± 4%. However, 10 μM TBQ also decreased the peak L-type Ca current by 23 ± 7%. At higher concentrations (100 μM), TBQ also activated an outward current with a current–voltage relationship consistent with a potassium current. This outward current was abolished by Glibenclamide (100 μM). These data show that TBQ can be used to reversibly inhibit SERCA. However, at concentrations that decrease SERCA activity, TBQ also decreases the L-type Ca current and (at higher concentrations) activates an outward current which appears to be an ATP dependent potassium current. We conclude that TBQ cannot be used as a specific inhibitor of SERCA in rat ventricular myocytes.

Cytokinin induced shoot regeneration and flowering of Scoparia dulcis L. (Scrophulariaceae)-an ethnomedicinal herb

OBJECTIVE

To develop an improved protocol for micropropagation of ethnomedicinally important Scoparia dulcis (S. dulcis) L.

METHODS

Explants were inoculated on MS basal medium supplemented with kinetin and 6-benzylaminopurine for shoot bud induction. To enhance the shoot induction, various auxins like 3-indoleacetic acid or 3-indolebutyric acid or α-naphthylacetic acid were tested along with 2.32 M KI and 4.44 µM BAP. The regenerated shoots were rooted in half strength MS medium supplemented with various concentrations of IAA, IBA or NAA. After roots were developed, the plantlets were transplanted to pots filled with vermiculate and sand and kept in growth chamber with 70%-80% humidity under 16 h photoperiod. After acclimatization, the plantlets were transferred to the garden and survival percentage was calculated. Data were statistically analyzed and means were compared using Duncan's multiple range test (P<0.05).

RESULTS

An in vitro method was developed to induce high frequency shoots regeneration from stem, mature leaf and young leaf explants of S. dulcis. Shoot induction on young leaf explants was most successful in MS medium supplemented with combination of two cytokinins (2.32 µM KI and 4.44 µM BAP) 2.85 µM IAA, 10% CM and 1 483.79 µM adenine sulfate. A single young leaf explant was capable of producing 59 shoots after 13 days of culture. Flower was induced in medium supplemented with combination of KI and BAP.

CONCLUSIONS

Cytokinins are the key factor to induce the direct shoot regeneration and flowering of S. dulcis.

Meta-analysis of the efficacy of cold coagulation as a treatment method for cervical intraepithelial neoplasia: a systematic review

BACKGROUND

Cold coagulation is an ablative method for treatment of cervical intraepithelial neoplasia (CIN). Despite reports of efficacy against all grades of CIN (CIN1-3), cold coagulation has been infrequently used since the 1980s, and was absent from the recent Cochrane review on CIN treatment.

OBJECTIVES

To provide a systematic review of cold coagulation efficacy and acceptability for CIN treatment through meta-analysis of clinical reports and a randomised control trial.

SEARCH STRATEGY

A literature search in PubMed, Web of Science, EMBASE, and regional databases yielded 388 papers. Title, abstract and/or reference list review identified 22 papers describing cold coagulation treatment of CIN, with 13 providing adequate data for inclusion in the meta-analysis.

SELECTION CRITERIA

Publications or conference abstracts describing original data (number of women treated, followed up and cured, provider type, cure definition) were retained. No language or publication date limitations were imposed.

DATA COLLECTION AND ANALYSIS

Data extracted from 13 studies were pooled, and statistical analyses of proportion cured were conducted with data stratified by lesion grade and study region.

MAIN RESULTS

Among 4569 CIN patients treated with cold coagulation, summary proportion cured of 96% [95% confidence interval (CI) 92-99%] and 95% (92-98%) were obtained for CIN1 and CIN2-3 disease, respectively. Side-effects and adverse effects were infrequent, and fertility was not impaired.

CONCLUSIONS

Cold coagulation CIN cure rates were comparable to those of other excisional and ablative methods. Cold coagulation is indicated for all grades of CIN, is safe, quick and acceptable, and may be of particular relevance for use in resource-limited settings.

Development of a cardiologist delivered service leads to improved outcomes following admission with acute coronary syndromes in a large district general hospital

BACKGROUND

East Lancashire Hospitals NHS Trust reorganized its services in October 2007 with acute admissions sent to one site which allowed the development of a 24/7 Consultant delivered cardiology service.

METHODS

A retrospective analysis of all patients admitted with an acute coronary syndrome between two periods: Group 1: October 2006 to September 2007 and Group 2: October 2007 and September 2008. We looked at the following end points-length of stay, in-hospital and 30 day all cause mortality.

RESULTS

633 patients in group 1 and 748 patients in group 2. There was significant reduction in length of stay from a median (IQ range) 7 (5-11) days to 5 (3-9) days; P<0.0001. The in-hospital mortality reduced from 15.8% (n=100) to 7.6% (n=56); P<0.0001. The mortality at 30 days reduced from 15.2% (n=96) to 8.3% (n=62); P<0.0001. These reductions remained significant after adjustment for demographic and risk factor variables.

CONCLUSION

A 24/7 Consultant Cardiologist delivered cardiac care is associated with marked reductions in all cause mortality following admission with acute coronary syndromes. This improvement occurred with a significant reduction in hospital length of stay.

Global oral health inequalities in incidence and outcomes for oral cancer: causes and solutions

The mouth and oropharynx are among the ten most common sites affected by cancer worldwide, but global incidence varies widely. Five-year survival rates exceed 50% in only the best treatment centers. Causes are predominantly lifestyle-related: Tobacco, areca nut, alcohol, poor diet, viral infections, and pollution are all important etiological factors. Oral cancer is a disease of the poor and dispossessed, and reducing social inequalities requires national policies co-ordinated with wider health and social initiatives - the common risk factor approach: control of the environment; safe water; adequate food; public and professional education about early signs and symptoms; early diagnosis and intervention; evidence-based treatments appropriate to available resources; and thoughtful rehabilitation and palliative care. Reductions in inequalities, both within and between countries, are more likely to accrue from the application of existing knowledge in a whole-of-society approach. Basic research aimed at determining individual predisposition and acquired genetic determinants of carcinogenesis and tumor progression, thus allowing for targeted therapies, should be pursued opportunistically.

Trends in cancer incidence in Chennai city (1982-2006) and statewide predictions of future burden in Tamil Nadu (2007-16)

BACKGROUND

This paper investigates cancer trends in Chennai and predicts the future cancer burden in Chennai and Tamil Nadu state, India, using data on 89 357 incident cancers from the Chennai registry during 1982-2006, published incidence rates from the Dindigul Ambilikkai Cancer Registry during 2003-06 and population statistics during 1982-2016.

METHODS

Age-specific incidence rates were modelled as a function of age, period and birth cohort using the NORDPRED software to predict future cancer incidence rates and numbers of cancer cases for the period 2007-11 and 2012-16 in Chennai. Predictions for Tamil Nadu state were computed using a weighted average of the predicted incidence rates of the Chennai registry and current rates in Dindigul district. RESULTS; In Chennai, the total cancer burden is predicted to increase by 32% by 2012-16 compared with 2002-06, with 19% due to changes in cancer risk and a further 13% due to the impact of demographic changes. The incidence of cervical cancer is projected to drop by 46% in 2015 compared with current levels, while a 100% increase in future thyroid cancer incidence is predicted. Among men, a 21% decline in the incidence of oesophageal cancer by 2016 contrasts with the 42% predicted increase in prostate cancer. The annual cancer burden predicted for 2012-16 is 6100 for Chennai, translating to 55 000 new cases per year statewide (in Tamil Nadu). Breast cancer would dislodge cervical cancer as the top-ranking cancer in the state, while lung, stomach and large bowel cancers would surpass cervical cancer in ranking in Chennai by 2016.

CONCLUSION

In order to tackle the predicted increases in cancer burden in Tamil Nadu, concerted efforts are required to assess and plan the infrastructure for cancer control and care, and ensure sufficient allocation of resources.

Cancer survival in Africa, Asia, the Caribbean and Central America. Introduction

The dearth of reliable survival statistics from developing countries was very evident until the mid-1990s. This prompted the International Agency for Research on Cancer (IARC) to undertake a project that facilitated hands-on-training and thereby transfer of knowledge and technology on cancer survival analysis to a majority of researchers from the participating population-based cancer registries, which culminated in the publication of the first volume of the IARC scientific publication on Cancer Survival in Developing Countries in 1998. The present study is the second in the series with wider geographical coverage and is based on data from 27 registries in 14 countries in Africa, Asia, the Caribbean and Central America. The calendar period of registration of incident cases for the present study ranges between 1990 and 2001. Data on 564 606 cases of 1-56 cancer sites from different registries are reported. Data from eleven registries were utilized for eliciting survival trend and seventeen registries for reporting survival by clinical extent of disease. Besides chapters on every registry and general chapters on methodology, database and overview, the availability of online comparative statistics on cancer survival data by participating registries or cancer site in the form of tables or graphs is an added feature (available online at http://survcan.iarc.fr).

Cancer survival in Africa, Asia, the Caribbean and Central America: database and attributes

Thirty-one registries in 17 countries submitted data for systematic and centralized scrutiny. Data on 564 606 cases of different cancers ranging 1-56 sites/types from 27 registries in 14 low-/medium-resource countries in Eastern and Western Africa, the Caribbean, Central America and four regions of Asia, registered during 1990-2001 (period varying for individual registries) were reported. The database for this survival study comprised data that were classified as mandatory and optional. Mandatory variables provided by all registries included case-ID, age at diagnosis, sex, incidence date, most valid basis of diagnosis, cancer site/type (ICD-10 codes C00-96), vital status at follow-up and corresponding date. Clinical extent of disease was prominent among the optional variables provided by 17 registries and analysed. The grouping of cancer sites for analysis was based on standard norms, and only categories with at least 25 cases were reported. Cases registered based on a death certificate only, cases lacking any follow-up after initial registration, or cases rejected based on validation checks were excluded from the survival analysis. An easy guide to contents in subsequent chapters, especially tables and graphs describing data quality indices, survival statistics and online dynamic functions, is provided.

Loss-adjusted hospital and population-based survival of cancer patients

This chapter presents formulae that methodologically adjust for losses, and gives examples describing magnitude of bias in survival estimates without such adjustment. Loss-adjusted survival is estimated under the assumption that survival of patients Lost to follow-up is the same as that for patients with known follow-up time and similar characteristics of different prognostic factors at first entry. The observed number of Losses to follow-up is then relocated into expected numbers of death and survivors on this basis. Standard methods, such as the actuarial one, are then applied with the sum of observed and expected outcome events. A total of 336 hospital series of treated new breast cancer cases from Mumbai with 24% lost to follow-up revealed a substantial bias of 7 per cent units for 3-year survival estimated with (54%) and without (61%) loss-adjustment. Stepwise adjustment of losses established that increasing the number of prognostic factors explained the bias better. Population-based series comprising 13 371 cases of top ranking cancers from Chennai, with loss to follow-up ranging from 7-24%, revealed negligible bias, ranging from 0-2% in 5-year survival by the loss-adjusted approach for different cancers. Data source seems to affect the need for loss-adjustment, and the loss-adjusted approach is recommended when hospital-based cancer registry data of a low- or medium-resource country are used to evaluate the outcome of cancer patients.

Cancer survival in the Gambia, 1993-1997

The national cancer registry of the Gambia was established in 1986 as part of the Gambia Hepatitis Intervention Study in collaboration with IARC, France; Medical Research Council (MRC) Laboratories of the UK; and the Government of the Gambia at MRC, Banjul. Registration of incident cancer cases is done by active and passive methods. For this study, the registry contributed data on survival for six cancer sites or types registered during 1993-1997. Follow-up has been carried out predominantly by active methods with median follow-up ranging between 1-6 months. The proportion of histologically verified diagnosis for various cancers ranged between 1-45%, and 54-82% of total registered cases were included for survival analysis. Complete follow-up at five years from the incidence date ranged between 81-98% for different cancers. The 5-year age-standardized relative survival for selected cancers were cervix (23%), non-Hodgkin lymphoma (22%), breast (10%), stomach (4%) and liver (3%). The 5-year relative survival by age group showed fluctuations with no definite pattern or trend emerging, and with no survivors in many age intervals.

An overview of cancer survival in Africa, Asia, the Caribbean and Central America: the case for investment in cancer health services

Population-based cancer survival data, a key indicator for monitoring progress against cancer, are reported from 27 population-based cancer registries in 14 countries in Africa, Asia, the Caribbean and Central America. In China, Singapore, the Republic of Korea, and Turkey, the 5-year age-standardized relative survival ranged from 76-82% for breast, 63-79% for cervical, 71-78% for bladder, and 44-60% for large-bowel cancer. Survival did not exceed 22% for any cancer site in The Gambia, or 13% for any cancer site except breast (46%) in Uganda. For localized cancers of the breast, large bowel, larynx, ovary, urinary bladder and for regional diseases at all sites, higher survival rates were observed in countries with more rather than less developed health services. Inter- and intra-country variations in survival imply that the levels of development of health services and their efficiency to provide early diagnosis, treatment and clinical follow-up care have a profound impact on survival from cancer. These are reliable baseline summary estimates to evaluate improvements in cancer control and emphasise the need for urgent investment to improve awareness, population-based cancer registration, early detection programmes, health-services infrastructure, and human resources in these countries in the future.

Research on cancer prevention, detection and management in low- and medium-income countries

The burden of cancer in low- and medium-income countries (LMIC) is expected to increase in the next decades. The application of current knowledge and results of research in key areas would contribute to limit the impact of this phenomenon. Opportunities for research on cancer prevention in LMIC include investigating specific circumstances of exposure to known carcinogens and to agents which are not prevalent in other regions, as well as interactions among carcinogens and between genetic and environmental factors. Early detection both by screening and early clinical diagnosis represents an important component of cancer control in LMIC. Research has been carried out to identify effective and sustainable approaches for early detection of cervical cancer through human papillomavirus testing and visual tests and of oral cancer through visual inspection. For other important neoplasms such as breast cancer, on the other hand, no effective low-cost screening methods are currently available. Downstaging represents a potentially important approach for cancer control and a priority area for future research. Studies addressing the efficacy of treatment protocols, country-specific cost-effectiveness of various interventions and the clinical utility and cost-effectiveness of innovative heath care and communication technologies represent the priority for clinical cancer research.

HPV vaccination: the promise & problems

Four-fifths of the cervical cancer burden in the world is experienced in developing countries. HPV genotypes 16 and 18 account for 70 per cent of cervical cancers and currently available vaccines targeting these two types confer a high degree of protection against HPV 16/18 infection and related cervical precancerous lesions. However, widespread implementation of HPV vaccination programs are challenged by the unaffordable high costs of the vaccines and the lack of effective vaccine delivery platforms for sexually naïve girls. Other unresolved issues include long-term protection, cross-protection against HPV types not included in the vaccine and whether booster doses will be needed. Sensitivities associated with a vaccine preventing a sexually transmitted infection in girls, lack of awareness, public demand and political will, lack of coordination between cancer control, sexual and reproductive health and vaccine delivery services are additional challenges. Reduced costs, simple vaccine regimes and strengthening vaccine delivery platforms for adolescents should eventually facilitate HPV vaccine introduction in developing countries.

Completed suicide in adults of rural Kerala: rates and determinants

BACKGROUND

India has witnessed a dramatic increase in suicide rates during the past few decades. The southern state of Kerala has been reporting the highest rates of suicide. Since suicide rates are estimated from death registries, they are likely to be under-reported because the civil registration system is incomplete and suicide deaths are poorly reported.

METHODS

A cohort of 132 000 participants (age 35 years and above) in Thiruvananthapuram (erstwhile Trivandrum) district, Kerala was followed up for mortality from 1996 to 2005, after having filled-in a lifestyle questionnaire at baseline. The cause of death was based on verbal autopsy. Suicide methods were recorded and rates were estimated, and suicide risks were calculated according to several socioeconomic factors.

RESULTS

During the follow up period, a total of 11 608 deaths, of which 385 were suicides (3.3% of total deaths), were registered. The overall suicide rate was 39.3/100 000 person-years among adults 35-90 years of age (men: 78/ 100000; women: 16.5/100000). The predominant methods of suicide were hanging, followed by poisoning and drowning. The suicide determinants were male gender, middle-age (40-60 years), Hindu, alcohol drinkers and secondary education level (< or = 7 years). Neither low socioeconomic level, living alone, nor being a married woman was associated with suicide risk.

CONCLUSION

Suicide rates were consistent with the official rates of Thiruvananthapuram district (37/100 000). However, our study population did not include the 14-34-year-old age-group which represents more than 37% of all suicides and hence it is more likely that the official rates are under-reported. Determinants of suicide were in line with previous studies.

Preliminary X-ray crystallographic analysis of ornithine acetyltransferase (Rv1653) from Mycobacterium tuberculosis

The gene product of open reading frame Rv1653 from Mycobacterium tuberculosis is annotated as encoding a probable ornithine acetyltransferase (OATase; EC 2.3.1.35), an enzyme that catalyzes two steps in the arginine-biosynthesis pathway. It transfers an acetyl group from N-acetylornithine to L-glutamate to produce N-acetylglutamate and L-ornithine. Rv1653 was crystallized using the sitting-drop vapour-diffusion method. The native crystals diffracted to a resolution of 1.7 A and belonged to space group P2(1)2(1)2(1), with unit-cell parameters a = 60.1, b = 99.7, c = 155.3 A. The preliminary X-ray study showed the presence of a dimer in the asymmetric unit of the crystals, which had a Matthews coefficient V(M) of 2.8 A(3) Da(-1).

Chapter 8: Screening for cervical cancer in developing countries

Organised and quality assured cytology-based screening programmes have substantially reduced cervical cancer incidence in many developed countries. However, there are considerable barriers to setting up cytology-based screening programs, particularly in developing countries. This has stimulated the search for novel and alternative approaches to cytology for cervical cancer prevention. These approaches generally perform as well as cytology, and sometimes better, although many of them have a lower specificity, resulting in higher false-positive rates. The possibility of linking screening to treatment in a one- or two-visit strategy appears to be safe, feasible and effective. Barriers to establishing screening programs and the pitfalls encountered differ from one country to the next. Country-specific solutions need to be found, while being cognizant of the criteria that have enabled successful screening programmes.

Synthesis of 3-(2-pyridyl)-2-substituted-quinazolin-4(3H)-ones as new analgesic and anti-inflammatory agents

A new series of 3-(2-pyridyl)-2-substituted-quinazolin-4(3H)-ones were synthesized by reacting the amino group of 2-hydrazino-3-(2-pyridyl)-quinazolin-4(3H)-one with a variety of aldehydes and ketones. The starting material 2-hydrazino-3-(2-pyridyl)-quinazolin-4(3H)-one was synthesized from 2-aminopyridine. The title compounds were investigated for analgesic, anti-inflammatory and ulcerogenic index activities. While the test compounds exhibited significant activity, compound 2-(1-ethylpropylidene)-hydrazino-3-(2-pyridyl)-quinazolin-4(3H)-one (AS2) showed moderate analgesic activity and compound 2-(1-methylbutylidene)-hydrazino-3-(2-pyridyl)-quinazolin-4(3H)-one (AS3) showed realistic anti-inflammatory activity when compared to the reference standard diclofenac sodium. Interestingly the test compounds showed only mild ulcerogenic side effect when compared to aspirin.

Water-mediated variability in the structure of relaxed-state haemoglobin

The crystal structure of high-salt horse methaemoglobin has been determined at environmental relative humidities (r.h.) of 88, 79, 75 and 66%. The molecule is in the R state in the native and the r.h. 88% crystals. At r.h. 79%, the water content of the crystal is reduced and the molecule appears to move towards the R2 state. The crystals undergo a water-mediated transformation involving a doubling of one of the unit-cell parameters and an increase in water content when the environmental humidity is further reduced to r.h. 75%. The water content is now similar to that in the native crystals and the molecules are in the R state. The crystal structure at r.h. 66% is similar, but not identical, to that at r.h. 75%, but the solvent content is substantially reduced and the molecules have a quaternary structure that is in between those corresponding to the R and R2 states. Thus, variation in hydration leads to variation in the quaternary structure. Furthermore, partial dehydration appears to shift the structure from the R state to the R2 state. This observation is in agreement with the earlier conclusion that the changes in protein structure that accompany partial dehydration are similar to those that occur during protein action.

An asymmetric dimer of beta-lactoglobulin in a low humidity crystal form--structural changes that accompany partial dehydration and protein action

Dimeric lactoglobulin molecules exist in the open conformation at basic pH, whereas they exist in the closed conformation at acidic pH, after undergoing the Tanford transition around neutral pH. Orthorhombic crystals consisting of molecules in the open conformation, grown close to neutral pH, undergo a water-mediated transformation when the relative humidity around the crystals is reduced. The two subunits in the dimer are related by a crystallographic twofold axis in the native crystals while the dimer is asymmetric in the low humidity form. Interestingly, one of the subunits in the dimer in the low humidity form is in an open conformation while the other is in a closed conformation. This is the first observation of such an asymmetric dimer. A hydrogen bond between the side chains of Gln35 and Tyr42 exists and the side chain of Glu89 is substantially buried in the closed subunit of the asymmetric unit, as in other structures with molecules in the closed conformation. However, the closure of the EF loop is not complete; its conformation can be described as half-closed. A comparison of different crystal structures of beta-lactoglobulin indicates that the conformation of the loops in the molecule is substantially influenced by other factors such as crystal packing, the pH, and the composition of the medium, while the change in the conformation of the EF loop follows the Tanford transition. The mutual disposition of the two subunits in the low humidity form is halfway between those in the open and closed structures. The present work further demonstrates that structural changes that occur during partial dehydration could mimic those that occur during the action of proteins.

High throughput crystallography of TB drug targets

Tuberculosis (TB) infects one-third of the world population. Despite 50 years of available drug treatments, TB continues to increase at a significant rate. The failure to control TB stems in part from the expense of delivering treatment to infected individuals and from complex treatment regimens. Incomplete treatment has fueled the emergence of multi-drug resistant (MDR) strains of Mycobacterium tuberculosis (Mtb). Reducing non-compliance by reducing the duration of chemotherapy will have a great impact on TB control. The development of new drugs that either kill persisting organisms, inhibit bacilli from entering the persistent phase, or convert the persistent bacilli into actively growing cells susceptible to our current drugs will have a positive effect. We are taking a multidisciplinary approach that will identify and characterize new drug targets that are essential for persistent Mtb. Targets are exposed to a battery of analyses including microarray experiments, bioinformatics, and genetic techniques to prioritize potential drug targets from Mtb for structural analysis. Our core structural genomics pipeline works with the individual laboratories to produce diffraction quality crystals of targeted proteins, and structural analysis will be completed by the individual laboratories. We also have capabilities for functional analysis and the virtual ligand screening to identify novel inhibitors for target validation. Our overarching goals are to increase the knowledge of Mtb pathogenesis using the TB research community to drive structural genomics, particularly related to persistence, develop a central repository for TB research reagents, and discover chemical inhibitors of drug targets for future development of lead compounds.

Effectiveness, safety and acceptability of 'see and treat' with cryotherapy by nurses in a cervical screening study in India

We evaluated a ‘see and treat’ procedure involving screening, colposcopy, biopsy and cryotherapy by trained nurses in one-visit in field clinics in a cervical screening study in South India for its acceptability, safety and effectiveness in curing cervical intraepithelial neoplasia (CIN). Women positive on visual inspection with acetic acid (VIA) were advised colposcopy, directed biopsies and cryotherapy if they had colposcopic impression of CIN in one visit by nurses in field clinics supervised by a doctor. Side effects and complications were assessed and cure rates were evaluated with VIA, colposcopy and biopsy if colposcopic abnormalities were suspected. Cure was defined as no clinical or histological evidence of CIN at ⩾6 months from treatment. Of the 2513 women offered ‘see and treat’ procedure, 1879 (74.8%) accepted. Of the 1397 women with histologically proved CIN treated with cryotherapy, 1026 reported for follow-up evaluation. Cure rates were 81.4% (752 out of 924) for women with CIN 1; 71.4% (55 out of 77) for CIN 2 and 68.0% (17 out of 25) for CIN 3. Minor side effects and complications were documented in less than 3% of women. ‘See and treat’ with cryotherapy by nurses under medical supervision is acceptable, safe and effective for cervical cancer prevention in low-resource settings.