A population‑based screening program for early detection of common cancers among women in India – methodology and interim results.

BACKGROUND: Cancers of the uterine cervix, breast, and oral cavity accounted for 134,420, 115,251, and 24,375 cases, respectively, and were responsible for 52.8% of the total cancers among women in India in 2008. AIM: The major objectives were to create awareness regarding common cancers among women, to detect pre‑cancers of the uterine cervix and oral cavity, and early cancers of the breast, uterine cervix, and oral cavity, by conducting screening with simple, low‑cost technology, within the community, and to facilitate confirmation of diagnosis among the screen positives and treatment and follow‑up among the diagnosed cases. SETTINGS AND METHODS: This is a community‑based screening program for early detection of breast, uterine cervix, and oral cancers, being implemented among the socioeconomically disadvantaged women in Mumbai, India. The process involves selection of clusters, household surveys, health education, and screening the eligible women for breast, uterine cervix, and oral cancers, by primary healthcare workers, at a temporarily set‑up clinic within the community. The program is planned to cover a 125,000 disadvantaged population in five years. RESULTS: Twenty‑one thousand and fifteen people, with 4009 eligible women, have been covered to date. The compliance for screening for breast, cervix, and oral cavity has been 85, 70, and 88% and the screen positivity rates are 3.9, 14.9, and 3.9%, respectively. Twenty‑seven oral pre‑cancers, 25 cervix pre‑cancers, one invasive cancer of the breast, two of the cervix, and one oral cavity cancer have been diagnosed among the screened women and all of them have complied with the treatment. CONCLUSIONS: The program is raising awareness about the common cancers and harms of tobacco among the disadvantaged women population in Mumbai. It is also helping in detecting pre‑cancers and cancers among asymptomatic women and is assisting them in receiving treatment.

Community-based tobacco cessation program among women in Mumbai, India.

BACKGROUND: Globally tobacco epidemic kills nearly six million people annually. Consumption of tobacco products is on the rise in low‑ and middle‑income countries. Tobacco is addictive; hence, tobacco users need support in quitting. AIMS: Providing tobacco cessation services to women in community enabling them to quit tobacco, identifying factors associated with quitting and documenting the processes involved to establish a replicable “model tobacco cessation program.” SETTINGS AND DESIGN: This is a community based tobacco cessation program of one year duration conducted among women in a low socioeconomic area of Mumbai, India. SUBJECTS AND METHODS: It involved three interventions conducted at three months interval, comprised of health education, games and counseling sessions and a post intervention follow‑up. STATISTICAL ANALYSIS: Uni and multivariate analysis was performed to find out association of various factors with quitting tobacco. RESULTS: The average compliance in three intervention rounds was 95.2%. The mean age at initiation of tobacco was 17.3 years. Tobacco use among family members and in the community was primary reasons for initiation and addiction to tobacco was an important factor for continuation, whereas health education and counseling seemed to be largely responsible for quitting. The quit rate at the end of the programme was 33.5%. Multivariate logistic regression analysis found that women in higher age groups and women consuming tobacco at multiple locations are less likely to quit tobacco. CONCLUSIONS: Changing cultural norms associated with smokeless tobacco, strict implementation of antitobacco laws in the community and work places and providing cessation support are important measures in preventing initiation and continuation of tobacco use among women in India.

Impact of 'gutkha and pan masala ban' in the state of Maharashtra on users and vendors.

BACKGROUND: Gutkha and pan masala contain harmful and carcinogenic chemicals. Hence, Maharashtra Government banned their manufacture, storage, distribution and sale on 19th July 2012 for a year. OBJECTIVES: The objective of this study is to determine the impact of the ban on gutkha and pan masala on its users and vendors. MATERIALS AND METHODS: A cross‑ sectional study was conducted among gutkha and/or pan masala users and tobacco vendors in the selected area of Mumbai city, 4‑6 months after the implementation of the ban. The parameters studied included knowledge regarding the ban, usage or discontinuation of use of the banned products, product availability, withdrawal symptoms among quitters, etc., RESULTS: A total of 68 users and five tobacco vendors were enrolled in this study. Although all users were aware about the ban on gutkha, very few knew about the ban on pan masala. Only 5.9% of users knew that currently the ban had been declared for only 1 year. Electronic media was the main source of information regarding the ban as reported by 45.6% users. All users and vendors were in favor of the ban. After the ban, 23.53% gutkha users quit their habit while 55.88% reduced their gutkha consumption. Non‑availability of gutkha was the most important reason stated by the gutkha users for quitting or reducing the consumption. In spite of the ban, gutkha is still available in the market, but at an increased cost or in a different form. CONCLUSION: Nearly 23.53% of gutkha users have quit their habit post‑ban despite its availability through illegal sources.

Analysis of position of greater palatine foramen in central Indian adult skulls: a consideration for maxillary nerve block.

To anaesthetize posterior part of soft palate for various surgical procedures, knowledge of the position of the greater palatine foramen (GPF) is very important. Blocking of maxillary division of trigeminal nerve or its branches for local anaesthesia is common practice for maxillofacial surgeries. Objective: this study was aimed to determine the morphology of greater palatine foramen in relation to certain fixed points. Methodology: this study was conducted on 86 dry adult Indian skulls. All the measurements were done with vernier caliper accurate to 0.1 mm. Using flexible stainless steel wire direction of opening of GPF into oral cavity was noted. Results: In 73.26% cases, GPF is located opposite third maxillary molar tooth. Mean distance from GPF to the incisive fossa (IF) was found to be 35.9 mm. The mean distance between posterior margins of GPF to posterior border of hard palate was 3.4 mm. The distance between the GPF to the midline maxillary suture was 15.3 mm. In 74.42% cases, direction of opening of GPF was located antero-laterally. Arched palatal vault was found in 66.28% skulls. Conclusion: The location of greater palatine foramen is variable still in most of the cases it is located opposite third molar tooth and is directed antero-later.

Call centre employees and tobacco dependence: Making a difference.

Context : India is known as the Business Process Outsourcing (BPO) capital of the world. Safeguarding health of millions of youngsters employed in this new growing economy is an occupational health challenge. Aims : This study was initiated in June 2007 in India with the objectives to assess the prevalence of tobacco use and study the factors responsible for initiating and continuing its use. The main aim, however, was to assess the effect of different tobacco cessation intervention strategies, thus identifying effective methods to assist these employees to quit tobacco. Materials and Methods : This is a 4-arm cluster randomized trial of 18 months duration among 646 BPO employees, working in 4 different BPO units. The employees were invited to participate in interviews following which tobacco users of each BPO were offered specific tobacco cessation interventions to assist them to quit tobacco use. Results : The prevalence of tobacco dependence is 41%, mainly cigarette smoking. The tobacco quit rate is similar (nearly 20%) in the 3 intervention arms. Significantly higher reduction in tobacco consumption of 45% is seen in Arm 4 with the use of pharmacotherapy. BPO employees change jobs frequently, hence follow-up remains a major challenge. Conclusion : Inaccessibility of pharmacotherapy in the developing countries should not deter tobacco cessation efforts as good tobacco quit rates can be achieved with health education and behavioral therapy. Tobacco cessation should be an integral activity in all BPOs, so that the employees receive this service continuously and millions of our youths are protected from the hazards of tobacco.

Prognostic significance of location of the primary tumor in operable breast cancers.

BACKGROUND: The prognostic significance of the primary tumor site in breast cancers is not established with only a few studies having evaluated the issue. MATERIALS AND METHODS: The relevance of a primary tumor site with respect to systemic disease relapse was evaluated in 187 patients with breast cancer treated with primary surgery and adjuvant chemotherapy, in whom the location of primary tumor was classifiable in any one of the three sites, namely: outer, periareolar, and inner, quadrants. Data was obtained from prospectively maintained records of breast cancer patients treated at a single surgical unit in a tertiary care center. RESULTS: The three groups were comparable with regard to demographic, pathological tumor, and treatment characteristics. In the multivariate analysis, patients with inner and periareolar quadrant tumors had a higher hazard for systemic disease relapse, (2.53, 95% CI: 1.18-5.42; P = 0.02, and 2.73, 95% CI: 1.04-7.14; P = 0.04, respectively) as compared to outer quadrant tumors. The projected five-year survival estimates in Kaplan Meier were 87%, 61%, and 69%, respectively, for outer, periareolar, and inner quadrant. On further substratification the difference was particularly noted in high risk inner quadrant tumors: age 45, premenopausal patients, tumor size> 2 cms, positive nodes and intermediate or high grade histology, as also in patients treated with breast conservation and CMF, Cyclophosphamide, Methorexate, 5 Fluorouracil chemotherapy. CONCLUSION: The location of the primary tumor influences survival in breast cancer with inferior outcome for tumors in inner and periareolar quadrants, especially in high risk groups and those treated with conservative approaches. The role of aggressive therapies merits investigation in these patients.

Hemorrhagic pseudocyst of the adrenal gland causing acute abdominal pain.

Acute abdominal pain is a common clinical entity with varied etiology. Hemorrhagic pseudocysts of the adrenal gland are rare lesions that might be considered in the differential diagnosis of acute abdominal pain. Herein, we report a case of young married female presenting with acute pain abdomen and fever, who was diagnosed to have hemorrhagic pseudocyst of the adrenal gland.

Second echelon node predicts metastatic involvement of additional axillary nodes following sentinel node biopsy in early breast cancer.

BACKGROUND: In many patients with early breast cancer, the sentinel lymph node (SLN) is the sole site of regional nodal metastasis. This subgroup of patients may not benefit from completion axillary lymph node dissection (CALND). AIMS: This pilot study evaluates the status of 2nd echelon (station) lymph nodes in the axilla as a predictor of additional positive nodes in the axilla in the presence of sentinel node metastasis. SETTINGS AND DESIGN: Cross-sectional study of 40 breast cancer patients. MATERIALS AND METHODS: Forty patients with invasive breast cancer underwent SLN biopsy followed by 2nd echelon lymph node biopsy in the same sitting. SLN mapping was performed using a combined technique of isosulfan blue and 99 mTc-sulfur colloid. SLNs (Station I) were defined as blue and/or hot nodes. These nodes were then injected with 0.1 ml of blue dye using a fine needle and their efferent lymphatic was traced to identify the Station II nodes. Then a complete ALND was performed. All the specimens were sent separately for histopathological evaluation. RESULTS: SLNs (Station I nodes) were successfully identified in 98% (39/40) patients. Of the 17 patients with a positive SLN, 8 (47%) patients had no further positive nodes in the axilla, 9 (53%) patients had additional metastasis in nonsentinel lymph nodes upon CALND. Station II nodes were identified in 76% (13/17) patients with a positive SLN. Station II nodes accurately predicted the status of the remaining axilla in 92% patients (12/13). STATISTICAL ANALYSIS: We calculated the Sensitivity, Negative predictive value, Positive predictive value, False negative rate and Identification rate. CONCLUSION: Station II nodes may predict metastatic involvement of additional nodes in the axilla.

Neoadjuvant chemotherapy in squamous cell carcinoma of the esophagus using low dose continuous infusion 5-fluorouracil and cisplatin: results of a prospective study.

BACKGROUND: Surgery is the treatment of choice for localized esophageal squamous cell carcinoma (ESCC). Despite curative surgical resection, the majority of patients develop local and systemic recurrence with poor 5-year survival. AIMS: To study the role of low dose continuous infusion (CI) 5-fluorouracil (5-FU) and cisplatin as neoadjuvant chemotherapy in ESCC. SETTINGS AND DESIGN: A non-randomized prospective study conducted over a period of two years (1996-1998) in the Department of Surgery, All India Institute of Medical Sciences, India. MATERIAL AND METHODS: Twenty-two patients with ESCC were included in the study. Chemotherapy consisted of a continuous 30-day infusion of 5-FU (350 mg/m2/day) and cisplatin (7.5 mg/m2/day), 5 days/week for 4 weeks. All patients had surgery following chemotherapy. RESULTS: A full course of chemotherapy was completed in 18 patients (82%). Chemotherapy was not completed due to non-compliance (n=2), thrombophlebitis (n=1), and vomiting (n=1). Grade-1 haematological and hepato-toxicity was observed in four patients. Thirteen patients developed thrombophlebitis. After chemotherapy, improvement in dysphagia was observed in 13 of 22 (59%) patients. Radiological partial response was observed in 8 patients (36.4%). 19 patients underwent surgical resection (86.4%) with zero mortality. Post-operative morbidity was observed in six patients (27%). Complete and partial pathological response was observed in two (11%) and one patient (5.5%) respectively. The overall median survival was 18 months and 4-year survival was 42%. CONCLUSIONS: Low dose CI 5-FU and cisplatin is well tolerated with minimal toxicity. Histopathological response rates and survival figures are comparable with the more toxic neoadjuvant chemotherapeutic regimens.

Wegener's granulomatosis: an isolated lung mass responding to antituberculosis therapy and atypical course.

We describe an unusual case of Wegener's granulomatosis (WG), in a middle aged, non-smoking female who presented with a lung mass with constitutional symptoms. FNABC from mass revealed a single ill-defined granuloma without necrosis. There was a definite clinical and radiological response to anti-tuberculosis treatment. She was later found to have another mass lesion in nasopharynx. ANCA was negative initially but became positive once disease flare up occurred. Multisystem involvement with clinical features of vasculitis were seen during the flare up and resulted in a fatal outcome. Unusual features and literature on this entity is discussed.

Intussusception due to gastrointestinal stromal tumour of the colon: diagnosis by colonoscopy.

Intussusception of the intestine is rare in adults. We report a case of a 45-year-old male who presented with long-standing pyrexia of unknown origin, abdominal pain, gastrointestinal bleeding and constitutional symptoms. Colonoscopic examination revealed a large invaginated mass suggestive of colonic intussusception due to gastrointestinal stromal tumour of the colon. His symptoms disappeared after surgical removal of the tumour.

Symptom score does not correlate with gastritis grade and Helicobacter pylori infection in non ulcer dyspepsia.

BACKGROUND: Non ulcer dyspepsia (NUD) is being postulated as one of the gastroduodenal manifestations of H. pylori infection. H. pylori infection may result in clinical symptoms as well as histological changes in NUD. AIM: To compare clinical symptom score and histological changes in H. pylori (Hp) positive and negative untreated NUD patients. METHODS: Forty six patients with dyspeptic symptoms and normal upper GI endoscopic examinations were included in this study. During endoscopy 2 biopsies each were taken from the antrum and body of the stomach. These biopsies were used for rapid urease test (RUT) and histological examination. Patients were diagnosed to have Hp infection if either of two tests were positive. There were two groups of patients: Hp positive and Hp negative NUD patients. Clinical scoring using Glasgow dyspepsia score (Max. 20) and histological analysis, using Sydney system (Max score 11) was done and compared for both the groups of patients. Clinical scoring, RUT and histological scoring were blinded to each other. RESULTS: H. pylori was present in 29(63%) of the 46 patients. Mean clinical score for H. pylori positive patient was 10.9 while for Hp negative patient was 11.4. Total histological score for Hp positive and Hp negative patients was 3.37 Vs 1.76 (antrum) and 3.68 Vs 1.29(body) (p < .001), respectively. The only histological change found to be statistically significant between Hp positive and Hp negative patients was presence of lymphoid follicles (p < .05). CONCLUSION: Clinical scoring does not correlate with the presence of H pylori or histological severity. In NUD patients positive for H. pylori, there is a significant increase in the severity of gastritis both in the antrum and the body.

Classical polyarteritis nodosa and microscopic polyangiitis--a clinicopathologic study.

OBJECTIVE: To describe the clinical spectrum, laboratory features, histopathological findings and treatment outcome in patients with classical polyarteritis nodosa (PAN) and microscopic polyangiitis (MPA). MATERIAL AND METHODS: Patients with PAN and MPA seen at a large teaching hospital in north India over a period of five years (1994-99) were included in the present study. RESULTS: We encountered five patients with PAN and six patients with MPA during the study period. Of the five patients with PAN, two had systemic disease while three had limited PAN. The patients with limited PAN included two with cutaneous PAN and one with PAN confined to the nerves. Constitutional symptoms, musculoskeletal complaints, peripheral neuropathy and skin lesions dominated the clinical picture. Fifty percent of the MPA patients presented as pulmonary renal syndrome. All the patients with PAN were HBsAg and ANCA negative and had normal urinalysis findings. In contrast, all patients with MPA demonstrated an active urine sediment and 83.3% were pANCA positive. Some of the rare features encountered by us were the presence of antiphospholipid syndrome and extensive interstitial lung disease in MPA, and spontaneous recovery in one patient with systemic PAN. Treatment outcome was better in PAN as compared with MPA. CONCLUSIONS: The clinical spectrum of PAN and MPA is quite varied. A good outcome is possible with the use of corticosteroids and cyclophosphamide.

Medullary thyroid carcinoma with melanin production--a case report.

Melanin production in medullary thyroid carcinomas is rare. The present case illustrates melanin and other atypical features of medullary carcinoma of the thyroid in a fifty year old female. The diagnosis was suggested on the cytomorphological features seen on fine needle aspiration cytology smears. On histo-pathological examination the tumor was extensively pigmented with frequent mitosis. Amyloid was conspicuously scarce. Confirmation of diagnosis was done by immunohistochemical positivity for calcitonin and HMB-45 on tissue sections. The case is being presented in view of its rarity and distinct immunoreactivity. Review of literature is done and the implications of such dual positivity in the histogenesis and divergent phenotype of this tumor are discussed.

Histologic chorioamnionitis & its association with prematurity in a hospital-based study.

This prospective study was undertaken to study the occurrence of histologic chorioamnionitis and determine its association with prematurity; and to assess whether colonization of the genital tract of pregnant women by genital mycoplasmas or Chlamydia trachomatis is a risk factor for histologic chorioamnionitis. A total of 268 women with singleton pregnancies of over 26 weeks gestation were subjected to high vaginal cultures of genital mycoplasmas and endocervical specimens for chlamydia antigen. Placental histopathology was performed on multiple sections. Histologic chorioamnionitis was documented in 22.4 per cent (60/208) placentae. Genital tract colonization with Ureaplasma urealyticum or C. trachomatis was not a risk factor for histologic chorioamnionitis. Neonates born in association with histologic chorioamnionitis had a mean birth weight 111 g lower than those born without this lesion (2626.9 +/- 702 g vs 2737.8 +/- 500 g, NS). The relative risk (95% confidence interval) of prematurity in the presence of histologic chorioamnionitis was 1.49 (0.87-2.53). Analysis of linear trend in proportions for prevalence of histologic chorioamnionitis with decreasing gestation showed a significant association (P = 0.047, 1-tail). These results taken together suggest that histologic chorioamnionitis may be a risk factor of prematurity, but of only a modest magnitude.

Prognostic significance of argyrophilic nucleolar organizer regions (AGNOR) in oesophageal cancer.

AgNOR (Argyrophilic nucleolar organiser region) has been shown in recent times, to have value in knowing the prognosis of carcinoma oesophagus. We have evaluated the significance of AgNOR in oesophageal cancer with reference to prognosis following treatment. Fifty patients of histologically proven squamous cell carcinoma of the oesophagus were studied. Following oesophagectomy the specimens removed were evaluated for AgNOR number. Of the resected specimens, 25 (50%) had an AgNOR count < or = 3.0, 18 (36%) had an AgNOR count of more than 3 per nucleus and in the remaining 7 cases, AgNOR number was not quantifiable due to the total absence of tumour tissue in the postoperative specimen due to preoperative radiotherapy. When followed up for an average period of 25 months (3 to 47 months), it was seen that patients with AgNOR count of < or = 3.0 per nucleous had a similar mean survival (30.39 +/- 3.29 months) as those with counts > 3.0 per nucleus (27.80 + 3.33 months). The survival in the seven patients in whom no tumour was present following preoperative radiotherapy, was 30.30 +/- 2.42 months. An analysis was done for the presence of change in the AgNOR count before and after radiotherapy in twenty eight case of carcinoma oesophagus treated with preoperative radiotherapy. It was found that the counts on an average were lower in patients after radiotherapy (2.89 +/- 1.04 per nucleus), than before radiotherapy (3.17 +/- 9.69). This was found in 24 cases, while the remaining 4 cases showed no change in count after radiotherapy. This suggested that radiotherapy caused a reduction in AgNOR counts. Mean survival in those with decreased count after radiotherapy was 33.65 (+/- 3.35) months. Since the AgNOR counting is a simple method and can be applied to paraffin embedded section, estimation of the AgNOR number may help in determination of prognosis in patients with oesophageal carcinoma. Preoperative radiotherapy seems to decrease AgNOR count with improved survival. These observations need however, to be reproduced with a larger sample size.