Occurrences, sources and health hazard estimation of potentially toxic elements in the groundwater of Garhwal Himalaya, India.

High concentrations of potentially toxic elements (PTEs) in potable water can cause severe human health disorders. Present study examined the fitness of groundwater for drinking purpose based on the occurrence of nine PTEs in a heavy pilgrim and tourist influx region of the Garhwal Himalaya, India. The concentrations of analyzed PTEs in groundwater were observed in the order of Zn > Mn > As > Al > Cu > Cr > Se > Pb > Cd. Apart from Mn and As, other PTEs were within the corresponding guideline values. Spatial maps were produced to visualize the distribution of the PTEs in the area. Estimated water pollution indices and non-carcinogenic risk indicated that the investigated groundwater is safe for drinking purpose, as the hazard index was < 1 for all the water samples. Assessment of the cancer risk of Cr, As, Cd, and Pb also indicated low health risks associated with groundwater use, as the values were within the acceptable range of ≤ 1 × 10-6 to 1 × 10-4. Multivariate statistical analyses were used to describe the various possible geogenic and anthropogenic sources of the PTEs in the groundwater resources although the contamination levels of the PTEs were found to pose no serious health risk. However, the present study recommends to stop the discharge of untreated wastewater and also to establish cost-effective as well as efficient water treatment facility nearby the study area. Present work's findings are vital as they may protect the health of the massive population from contaminated water consumption. Moreover, it can help the researchers, governing authorities and water supplying agencies to take prompt and appropriate decisions for water security.

Improving Utility of Data on Cancer Mortality Risk Associated with Smokeless Tobacco: Recommendations for Future Research

Background: We analyzed in detail the studies utilized in most recent global systematic review of risk of cancer mortality with smokeless tobacco (SLT) use to report challenges in the available data that limit the understanding of association between SLT use and cancer mortality. Methods: For each study, we documented study design, reporting of mortality risk by type of SLT variant, SLT use frequency, and sex of SLT user for oral, oesophageal, pharyngeal, laryngeal and orolaryngeal cancers. These findings are discussed within the context of prevalence of SLT use by geographic regions and sex. Results: Majority of studies reported mortality risk for oral (70.6%) followed by oesophageal cancer (38.2%). The availability of population-based evidence was low (35.3%). The geographic distribution of studies did not reflect the geographic distribution of countries with high SLT consumption; 61.8% of the studies were from India followed by Sweden (20.6%). Hospital-based (84.2%) studies reported risk with chewing tobacco and the population-based studies (61.5%) with non-chewing tobacco. Hardly any study reported on a particular type of SLT. Definition of SLT use as current, ever or former was limited without consideration of the wide variations in frequency and duration of use within these patterns. Mortality risk reporting for males dominated all cancers other than oral (50% males). Conclusions: Unless the methodological and generalizability challenges identified in this review are addressed in future research to develop a stronger scientific basis of the association of SLT use and cancer mortality, we would continue to face significant challenges in monitoring the health effects of SLT.

Three-dimensional transesophageal echocardiography-guided transcathetar closure of ruptured noncoronary sinus of valsalva aneurysm.

Sinus of Valsalva aneurysm accounts for only 1% of congenital cardiac anomalies. Sinus of Valsalva aneurysm can cause aortic insufficiency, coronary artery flow compromise, cardiac arrhythmia, or aneurysm rupture. Three-dimensional transesophageal echocardiography (3DTEE) represents an adjunctive tool to demonstrate the ruptured sinus of Valsalva with better delineation. We present an adult patient with rupture of noncoronary sinus of Valsalva aneurysm into the right atrium (RA). 3DTEE accurately delineated the site of rupture into the RA and showed the exact size and shape of the defect, which helped in the successful transcatheter closure of the defect with a duct occluder device.

Global, Regional, and National Cancer Incidence, Mortality, Years of Life Lost, Years Lived With Disability, and Disability-Adjusted Life-years for 32 Cancer Groups, 1990 to 2015: A Systematic Analysis for the Global Burden of Disease Study.

IMPORTANCE: Cancer is the second leading cause of death worldwide. Current estimates on the burden of cancer are needed for cancer control planning. OBJECTIVE: To estimate mortality, incidence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) for 32 cancers in 195 countries and territories from 1990 to 2015. EVIDENCE REVIEW: Cancer mortality was estimated using vital registration system data, cancer registry incidence data (transformed to mortality estimates using separately estimated mortality to incidence [MI] ratios), and verbal autopsy data. Cancer incidence was calculated by dividing mortality estimates through the modeled MI ratios. To calculate cancer prevalence, MI ratios were used to model survival. To calculate YLDs, prevalence estimates were multiplied by disability weights. The YLLs were estimated by multiplying age-specific cancer deaths by the reference life expectancy. DALYs were estimated as the sum of YLDs and YLLs. A sociodemographic index (SDI) was created for each location based on income per capita, educational attainment, and fertility. Countries were categorized by SDI quintiles to summarize results. FINDINGS: In 2015, there were 17.5 million cancer cases worldwide and 8.7 million deaths. Between 2005 and 2015, cancer cases increased by 33%, with population aging contributing 16%, population growth 13%, and changes in age-specific rates contributing 4%. For men, the most common cancer globally was prostate cancer (1.6 million cases). Tracheal, bronchus, and lung cancer was the leading cause of cancer deaths and DALYs in men (1.2 million deaths and 25.9 million DALYs). For women, the most common cancer was breast cancer (2.4 million cases). Breast cancer was also the leading cause of cancer deaths and DALYs for women (523 000 deaths and 15.1 million DALYs). Overall, cancer caused 208.3 million DALYs worldwide in 2015 for both sexes combined. Between 2005 and 2015, age-standardized incidence rates for all cancers combined increased in 174 of 195 countries or territories. Age-standardized death rates (ASDRs) for all cancers combined decreased within that timeframe in 140 of 195 countries or territories. Countries with an increase in the ASDR due to all cancers were largely located on the African continent. Of all cancers, deaths between 2005 and 2015 decreased significantly for Hodgkin lymphoma (-6.1% [95% uncertainty interval (UI), -10.6% to -1.3%]). The number of deaths also decreased for esophageal cancer, stomach cancer, and chronic myeloid leukemia, although these results were not statistically significant. CONCLUSION AND RELEVANCE: As part of the epidemiological transition, cancer incidence is expected to increase in the future, further straining limited health care resources. Appropriate allocation of resources for cancer prevention, early diagnosis, and curative and palliative care requires detailed knowledge of the local burden of cancer. The GBD 2015 study results demonstrate that progress is possible in the war against cancer. However, the major findings also highlight an unmet need for cancer prevention efforts, including tobacco control, vaccination, and the promotion of physical activity and a healthy diet.

Role of transesophageal echocardiography: a rare case of acute left atrial free wall dissection.

Transesophageal echocardiography (TEE) has been used routinely in the diagnosis and follow-up of cardiac cases. Left atrial dissection (LAd), an exceedingly rare complication of cardiac surgery, is most commonly associated with mitral valve surgery. A case of LAd is presented, and the pathology was accurately defined and immediately diagnosed using intraoperative TEE. This case highlights the importance of prompt diagnosis of LAd using intraoperative TEE, and a second cardiac surgery was avoided.

Evaluation of continuous non-invasive arterial pressure monitoring during induction of general anaesthesia in patients undergoing cardiac surgery.

BACKGROUND AND AIMS: Continuous arterial pressure monitoring is essential in cardiac surgical patients during induction of general anaesthesia (GA). Continuous non-invasive arterial pressure (CNAP) monitoring is fast gaining importance due to complications associated with the invasive arterial monitoring. Recently, a new continuous non-invasive arterial pressure device (CNAP™) has been validated perioperatively in non-cardiac surgeries. The aim of our study is to compare and assess the performance of CNAP during GA with invasive arterial pressure (IAP) in patients undergoing cardiac surgeries. METHODS: Sixty patients undergoing cardiac surgery were included. Systolic, diastolic, and mean arterial pressure (MAP) data were recorded every minute for 20 min simultaneously for both IAP and CNAP™. Statistical analysis was performed using mountain plot and Bland Altman plots for assessing limits of agreement and bias (accuracy) calculation. Totally 1200 pairs of data were analysed. RESULTS: The CNAP™ systolic, diastolic and MAP bias was 5.98 mm Hg, -3.72 mm Hg, and - 0.02 mm Hg respectively. Percentage within limits of agreement was 96.0%, 95.2% and 95.7% for systolic, diastolic and MAP. The mountain plot showed similar results as the Bland Altman plots. CONCLUSION: We conclude CNAP™ provides real-time estimates of arterial pressure comparable to IAP during induction of GA for cardiac surgery. We recommend CNAP can be used as an alternative to IAP in situations such as cardiac patients coming for non-cardiac surgeries, cardiac catheterization procedures, positive Allen's test, inability to cannulate radial artery and vascular diseases, where continuous blood pressure monitoring is required.

Contact with HIV prevention programmes & willingness for new interventions among truckers in India.

BACKGROUND & OBJECTIVES: Systematic data on existing coverage and willingness for HIV prevention strategies among truckers are not readily available in India. The present study aimed to further the understanding on contact of truckers with existing HIV prevention services and to assess willingness for new HIV prevention strategies. METHODS: A total of 1,800 truck drivers and helpers aged 16-65 yr passing through Hyderabad were approached to assess contact made with HIV prevention programmes, history of previous HIV testing and their acceptance for circumcision, oral HIV testing, new medications to control HIV (PrEP) and telephonic counselling. Dried blood samples were collected on filter paper and tested for HIV. Multiple logistic regression was performed for analysis of association between contact with HIV prevention programme and socio-demographic, sexual risk behaviour variables and work characteristics. RESULTS: A total of 1,602 (89%) truckers gave interview and provided blood sample. Forty five truckers tested positive for HIV resulting in HIV prevalence of 2.8 per cent (95% CI 2.0-3.6%). Only 126 truckers (7.9%; 95% CI 6.5-9.2%) reported ever being contacted by staff providing HIV prevention interventions. Previous HIV testing was reported by19 per cent (95% CI 17.3-21.2%). Those reporting contact with HIV prevention programmes ever were more likely to have undergone HIV testing (odds ratio 3.6, 95% CI 2.4-5.4). The acceptance for pre-exposure prophylaxis (PrEP) was 87 per cent, oral HIV testing 98 per cent, and telephonic counselling 82 per cent, but was only 9 per cent for circumcision.Truckers who reported having sex with a man and those who halted regularly at dhabas were significantly more willing to undergo circumcision for HIV prevention (odds ratios 2.7, 95% CI 1.4-5.4 and 2.1, 95% CI 1.3-3.2, respectively). INTERPRETATION & CONCLUSIONS: Our findings showed that truckers had low contact with HIV prevention programmes, suggesting a need for urgent measures to reach this population more effectively. The willingness for new HIV interventions was high except for circumcision. These findings could be used for further planning of HIV prevention programmes for truckers in India.

An in vitro evaluation of microtensile bond strength of resin-based sealer with dentin treated with diode and Nd:YAG laser.

BACKGROUND: Smear layer is a negative factor which prevents adhesion of the filling material to the dentinal walls. Recent advances in dental research have incorporated lasers as a potential adjunct in root canal treatment by removing the smear layer before filling the root canal system, enhancing the adhesion of sealers to dentin and improving the sealing ability. AIM: To evaluate the microtensile bond strength of AH-Plus resin-based sealer to dentin after treatment with 980 nm diode and 1,064 nm neodymium-doped:yttrium aluminum garnet (Nd:YAG) laser in vitro. MATERIALS AND METHODS: Thirty specimens prepared for three groups namely group I (control), group II (980 nm diode-lased specimens) and group III (Nd:YAG-lased specimens). One tooth from each group was observed under scanning electron microscope for evaluation of intracanal root dentin morphology. Remaining specimens were used for making microsections by hard tissue microtome. Specimens for groups II and III were lased with 980 nm diode and 1,064 nm Nd:YAG laser. AH Plus sealer was applied onto specimens and mounted onto Instron universal testing machine for microtensile bond strength testing. Results were subjected to statistical analysis using one-way analysis of variance (ANOVA) and Tukey's test. RESULTS: Group III Nd:YAG had maximum mean microtensile bond strength values (11.558 ± 0.869), followed by group II diode (9.073 ± 0.468) and group I control (6.05 ± 0.036). Statistically significant differences were seen among all the groups. SEM analysis shows removal of smear layer in both groups II and III. CONCLUSION: Both Nd:YAG and diode laser were more effective than control group in improving the microtensile bond strength of AH Plus sealer to dentin. CLINICAL SIGNIFICANCE: Lasers have the potential to increase the adhesiveness of root canal sealer to dentin surface, thereby improving the quality of root canal obturation.

HIV incidence from the first population-based cohort study in India.

BACKGROUND: Understanding about who acquires new HIV infection and the determinants of why some persons get infected and others do not is fundamental to controlling HIV in the population. We assess HIV incidence and its associations in the population of a high HIV burden district in Andhra Pradesh state in southern India by a population-based longitudinal cohort study. METHODS: We re-surveyed a population-based cohort of 12,617 adults in Guntur district of Andhra Pradesh for which we had reported a baseline HIV prevalence of 1.72% (rural 1.64%, urban 1.89%) among the 15-49 years age group in 2004-2005. We conducted interviews to assess risk behaviour and performed HIV testing again in 2010-2011. We assessed the rate of new HIV infection and its associations using multiple logistic regression. RESULTS: The participation rate in the follow-up was 74.9% and 63.9% of the baseline rural and urban samples, respectively. Over a mean follow-up of 5.63 years, the incidence of HIV was 1.26 per 1000 person-years (95% CI 0.83-1.69), after adjusting for slight compositional bias in the follow-up sample. The incidence per 1000 person-years was higher among rural men (1.68) than urban men (0.85), and among rural women (1.28) than urban women (0.54). The strongest association with incidence was a HIV positive spouse in the baseline for both men (odds ratio 266, 95% CI 62-1137) and women (odds ratio 28, 95% CI 9-88). Among men the other significant associations with HIV incidence were frequent use of condom for sex over the past 6 months, non-circumcision, more than one lifetime woman sex partner or ever visited sex worker, and transport-related occupation; for women the other significant associations were having had HIV testing other than antenatal check-up, previously married but currently not, and tobacco use. CONCLUSION: These first population-based cohort incidence data from India suggest that rural areas of high HIV burden states would need more attention to prevent new HIV infections, and that spouses of HIV positive persons and some other risk groups need to be targeted more effectively by HIV prevention programmes.

Behavioral surveillance of premarital sex among never married young adults in a high HIV prevalence district in India.

In a population-based representative sample of 2,475 never married persons aged 15-24 years from Guntur district of Andhra Pradesh state in India, 21.7% (95% CI 18.7-24.7) males and 4.6% (95% CI 2.2-7.0) females reported having had sex. Only 22.3% males and 6.3% females reported consistent condom use for premarital sex in the last 6 months. The strongest associations with premarital sex for males were current use of alcohol and tobacco, and for females were not living with parents currently and being an income earner. These findings can inform HIV prevention efforts among young adults in India.

Population-based seroprevalence of HSV-2 and syphilis in Andhra Pradesh state of India.

BACKGROUND: Understanding the prevalence and risk factors for common causes of ulcerative genital disease in the general population would inform current STI syndromic management and HIV testing strategies in high HIV prevalence regions of India. METHODS: Persons 15-49 years old from 32 rural and 34 urban clusters were sampled using a stratified random method to represent adults in the high HIV prevalence Guntur district in Andhra Pradesh state. Interviews were conducted and dry blood spots were collected on 12,617 study participants. Testing for HSV-2 and syphilis was performed. RESULTS: Adjusted HSV-2 and syphilis seroprevalence rates were 4.70% and 2.08% for men and 7.07% and 1.42% for women. For men, tattooing, >3 lifetime sex partners, tobacco use, and sex with men in the past 6 months were associated with HSV-2 or syphilis (ORs, 1.66-2.95, p < 0.05). Male circumcision was positively associated with HSV-2 infection (OR, 1.37, p = 0.028) though this could be due to residual confounding. In women, greater than one lifetime partner remained significantly associated with HSV-2 in multivariate analysis (OR, 2.61; 95% CI, 1.39-4.87). Among all behavioral risk factors and other covariates in women and men, HIV infection exhibited the strongest association with HSV-2 and syphilis (ORs, 8.2-14.2, p < 0.001). The proportion of individuals with HSV-2 who were HIV infected was less than the proportion with syphilis who were HIV infected (11.8% vs. 22.7%; p = 0.001). CONCLUSIONS: Nearly one in four persons surveyed in this population-based study that were seroprevalent for syphilis, were also HIV infected. Common population risk factors for syphilis, HSV-2 and HIV and high rates of co-seroprevalence suggest that HIV testing, STI testing and service strategies for these would benefit from direct linkage in India.

Application of human immunodeficiency virus type 1 BED enzyme immunoassay on dried blood spots in India.

Dried blood spots (DBSs) on filter paper are being used increasingly in population-based human immunodeficiency virus (HIV) studies. This study evaluated the application of a BED enzyme immunoassay (EIA) on DBSs to estimate HIV incidence in a population-based study in India. The Calypte HIV-1 BED Incidence EIA was performed on 224 HIV-1-positive DBS samples, after screening 12 617 individuals from a population-based sample in Guntur district in the southern Indian state of Andhra Pradesh. The number of recently infected HIV cases was identified using this BED assay and was used to estimate the annual HIV incidence rate based on calculations and adjustment formulae suggested by the Centers for Disease Control and Prevention (CDC). The updated BED data management software provided by the CDC was used for analyses. Of the 224 HIV-1 antibody-positive DBS samples, 29 (12.95 %) were estimated by the BED HIV-1 assay to have been infected within the past 155 days. After adjusting for age, gender and rural/urban distribution of the population, the annual incidence rate of HIV-1 infection was estimated to be 0.32 % (95 % confidence interval 0.20-0.44 %). This annual incidence was 18.6 % of the HIV prevalence of 1.72 % in this study. Thus, the BED assay revealed a higher incidence of HIV in this study than was expected from the prevalence. Correlation of the BED assay with panel testing and longitudinal incidence data in the Indian population is needed to calibrate it for use in India.

A population-based study of human immunodeficiency virus in south India reveals major differences from sentinel surveillance-based estimates.

BACKGROUND: The human immunodeficiency virus (HIV) burden among adults in India is estimated officially by direct extrapolation of annual sentinel surveillance data from public-sector antenatal and sexually transmitted infection (STI) clinics and some high-risk groups. The validity of these extrapolations has not been systematically examined with a large sample population-based study. METHODS: We sampled 13838 people, 15-49 years old, from 66 rural and urban clusters using a stratified random method to represent adults in Guntur district in the south Indian state of Andhra Pradesh. We interviewed the sampled participants and obtained dried blood spots from them, and tested blood for HIV antibody, antigen and nucleic acid. We calculated the number of people with HIV in Guntur district based on these data, compared it with the estimate using the sentinel surveillance data and method, and analysed health services use data to understand the differences. RESULTS: In total, 12617 people (91.2% of the sampled group) gave a blood sample. Adjusted HIV prevalence was 1.72% (95% confidence interval 1.35-2.09%); men 1.74% (1.27-2.21%), women 1.70% (1.36-2.04%); rural 1.64% (1.10-2.18%), urban 1.89% (1.39-2.39%). HIV prevalence was 2.58% and 1.20% in people in the lower and upper halves of a standard of living index (SLI). Of women who had become pregnant during the past 2 years, 21.1% had used antenatal care in large public-sector hospitals participating in sentinel surveillance. There was an over-representation of the lowest SLI quartile (44.7%) in this group, and 3.61% HIV prevalence versus 1.08% in the remaining pregnant women. HIV prevalence was higher in that group even when women were matched for the same SLI half (lower half 4.39%, upper 2.63%) than in the latter (lower 1.06%, upper 1.05%), due to referral of HIV-positive/suspected women by private practitioners to public hospitals. The sentinel surveillance method (HIV prevalence: antenatal clinic 3%, STI clinic 22.8%, female sex workers 12.8%) led to an estimate of 112635 (4.38%) people with HIV, 15-49 years old, in Guntur district, which was 2.5 times the 45942 (1.79%) estimate based on our population-based study. CONCLUSION: The official method in India leads to a gross overestimation of the HIV burden in this district due to addition of substantial extra HIV estimates from STI clinics, the common practice of referral of HIV-positive/suspected people to public hospitals, and a preferential use of public hospitals by people in lower socioeconomic strata. India may be overestimating its HIV burden with the currently used official estimation method.