The Lifetime Health and Economic Burden of Smokeless Tobacco use in Bangladesh, India, and Pakistan: Results From ASTRAMOD.

INTRODUCTION: Under the current policy landscapes, the lifetime health and economic burden of smokeless tobacco (ST) products, consumed by over 297 million ST users in South Asia, is unknown. The aim of this study was to estimate the lifetime health effects and costs attributable to current and future ST use in Bangladesh, India, and Pakistan where the majority of ST users live. AIMS AND METHODS: We developed a Markov-based state-transition model (ASTRAMOD) to predict the lifetime costs of treatment of four diseases (oral, pharyngeal, esophageal cancers, and stroke) and disability-adjusted life years (DALYs), attributable to the current and future use of ST under existing ST policy scenario. Country-specific Global Adult Tobacco Surveys, life tables, and meta-analyses of South Asian and South East Asian studies were used to populate the model. A probabilistic sensitivity analysis evaluated the uncertainty in model predictions. RESULTS: If there were no change in the current ST policies, the lifetime ST-attributable treatment costs would be over US$19 billion in India, over US$1.5 billion in Bangladesh, and over US$3 billion in Pakistan. For all countries, the attributable costs are higher for younger cohorts with costs declining with increasing age for those over 50. The model predicted that a typical 15-year-old male adoloscent would gain 0.07-0.18 life years, avert 0.07-0.19 DALYs, and generate a cost-savings of US$7-21 on healthcare spending if ST policies were changed to eliminate ST use. CONCLUSIONS: Policy interventions aimed at decreasing the uptake of ST and increasing quitting success have the potential to substantially decrease the economic and health burden of ST. IMPLICATIONS: This study provides the most comprehensive estimates of the lifetime health and economic burden of ST by 5-year age and sex cohorts. This is also the first study that highlights the scale of health and economic burden of ST in Bangladesh, India, and Pakistan if there were no changes in the current ST policies. Policymakers and practitioners can use the reported data to justify their decisions to improve current ST policies and practices in their country. Researchers can use the ASTRAMOD methodology to estimate the impact of future ST policy changes.

Efficacy of perioperative systemic tranexamic acid along with topical hemocoagulase in decreasing axillary drain output in breast cancer patients undergoing axillary lymph node dissection: A randomized, double-blind, placebo-controlled, superiority trial.

BACKGROUND: Excess and prolonged axillary drainage is a frequent nuisance following axillary lymph node dissection (ALND) in breast cancer patients. No consensus exists about the best method to prevent this consistently and reliably. Tranexamic acid (TA) has been found to reduce the amount and duration of drainage, but the reduction is not optimal. We hypothesized that systemic administration of TA along with the topical application of hemocoagulase (H) to the axillary dissection bed may decrease the cumulative axillary drain output and shorten the requirement of drainage after ALND as compared to placebo. PATIENT AND METHODS: Seventy women undergoing ALND for breast carcinoma were randomized into two groups, the intervention (TA + H) group and the control (C) group. The cumulative drain output (primary objective), duration of drainage, incidence of seroma formation after drain removal, number of seroma aspirations required, volume of seroma aspirated, and incidence of surgical site infection (SSI) were compared. RESULTS: The mean cumulative output in the TA + H group was significantly lower than the C group (290 ± 200 mL vs. 552 ± 369 mL, p < 0.001). Axillary drains were removed significantly earlier in the TA + H group (6.6 ± 2.2 vs. 11.7 ± 6.0 days, p < 0.001), but the incidence of seroma formation (p = 0.34), number of aspirations required (p = 0.33), volume of seroma aspirated (p = 0.47), and the incidence of SSI (p = 0.07) were similar. CONCLUSIONS: Perioperative systemic administration of tranexamic acid along with topical application of H to the axillary dissection bed is effective in reducing cumulative axillary drain output after ALND. This strategy may also facilitate earlier removal of suction drains.

How Does Tobacco Use Affect the Cognition of Older Adults? A Propensity Score Matching Analysis Based on a Large-Scale Survey.

INTRODUCTION: Tobacco is a well-established risk factor for cancer, but its association with other morbidities needs consideration. The low-income and middle-income countries (LMICs) with unprecedented demographic transformation lack evidence on tobacco use and its impact on cognitive health. AIMS AND METHODS: Using a propensity score matching approach, we utilized data from the Longitudinal Ageing Study of India. Study employed 1:1 nearest neighbor matching with the replacement methodology. We estimated the odds of the poor cognitive score and tobacco use among older adults based on five different models for ever tobacco user, former tobacco user, current tobacco user, current smokers, and current smokeless tobacco users with reference to never tobacco users. RESULTS: The estimated average treatment effect for the treated and the untreated group has shown a higher likelihood of cognitive decline among ever (OR -0.26; 95%CI -0.43 to -0.09), current (OR -0.28; 95%CI -0.45 to -0.10), and former (OR -0.53; 95%CI -0.87 to -0.19) tobacco users compared to never tobacco users. The finding further suggests the odds of lower cognitive scores among older adults who were smokers (OR -0.53; 95%CI -0.87 to -0.19) and smokeless tobacco users (OR -0.22; 95%CI -0.43 to -0.01) as compared to never tobacco users. CONCLUSIONS: Interventions designed to prevent the incidence of cognitive impairment should focus on limiting the use of tobacco. Strategies under the tobacco-free generation initiative should be amplified in order to prevent future generations from productivity loss, premature ageing and to promote healthy aging. IMPLICATIONS: Evidence of a definitive association between tobacco consumption and cognition among older adults is sporadic in LMICs. Though tobacco is a risk factor for various diseases including cancer, the extent of its impact on cognitive health among the older population is limited. This study contributes to the existing literature by highlighting poor cognitive outcomes among older adults who smoke tobacco and/or consume smokeless tobacco as compared to never-tobacco users. Our findings emphasize the need to accelerate programmes related to tobacco-free generation in LMICs to reach a higher quality of life and healthy aging in pursuit of achieving the sustainable development goal of "good health and well-being."

Trends in age of tobacco use initiation over time in Bangladesh, India and Pakistan: analysis of cross-sectional nationally representative surveys.

OBJECTIVE: Tobacco use begins at an early age and typically leads to a long-term addiction. The age of initiation for tobacco use is not well studied in South Asia, where 22% of tobacco smokers and 81% of smokeless tobacco (SLT) users reside. METHODS: Data from the nationally representative Global Adult Tobacco Surveys in India, Bangladesh and Pakistan were analysed to examine patterns of initiation among smokers and smokeless tobacco users. RESULTS: Data on 94 651 individuals were analysed, of which 13 396 reported were ever daily smokers and 17 684 were ever SLT users. The proportion of individuals initiating tobacco use before the age of 15 years has increased over time. The rates of SLT initiation among those aged 15-24 years increased markedly in Bangladesh (by 7.8%) and Pakistan (by 37.7%) between 1983 and 1999-2000. Among males, the increase in SLT initiation was higher in individuals aged below 15 years compared with other age groups in India and Bangladesh. Smoking initiation among females aged below 15 years has also significantly increased in India over time. Compared with the initiation of tobacco smoking before the age of 15 years, a greater increase in the proportion of SLT users was observed in urban areas. CONCLUSION: Our findings indicate that the proportion of youth initiating tobacco (both smoking and smokeless) before the age of 15 years has increased over time in all three countries. Moreover, variations in age at initiation for different types of tobacco products across countries, and by rurality, were noticeable. Younger youths (aged up to 15 years) should therefore be a priority population for tobacco control interventions. Strategies such as raising the legal age of tobacco sale and use to 21 years, and, other measures under WHO Framework Convention on Tobacco Control (FCTC), may prevent underage use and avert lifelong addiction to tobacco products.

Tobacco exposure among antenatal women in India: Challenges in tobacco screening & cessation counselling.

Links between tobacco use and poor pregnancy outcomes are well established. Despite various tobacco control measures taken by the government, nearly 5-8 per cent of pregnant women consume tobacco in India. Antenatal check-ups are an opportunity to assess and assist women in quitting tobacco during pregnancy. This review highlights the challenges faced in identifying pregnant tobacco users and providing cessation counselling to them in a formal healthcare setup in the Indian context. For this narrative review, open access databases like PubMed and Google Scholar were searched, using the following search terms: challenges, quitting tobacco use, smokeless tobacco, pregnancy and India. Original articles published between 2010 and July 2022 were included in the English language with available free full text. Out of the thirty articles found to be eligible, seven were included in the review. Official websites of the National Health Mission and National Tobacco Control Programme were also searched to retrieve available data on health education and training material for healthcare workers: medical officers, Auxiliary Nurse and Midwives (ANMs), Accredited Social Health Activists (ASHAs) and list of tobacco cessation centres. This review identified the factors such as myths surrounding tobacco use, lack of targeted screening, inadequate training of healthcare workers and inaccessibility of cessation services, which are posing as challenges in controlling tobacco use in this vulnerable section of the population. Specific strategies to address these issues at the micro, meso and macro levels can prove to be vital in controlling tobacco use in pregnant women. This review also identified the vital role of gynaecologists and healthcare workers such as ANMs and ASHA in identifying and providing brief tobacco cessation counselling to pregnant users.

Breast carcinoma presenting with upper limb lymphedema - A rare case.

Lymphedema (LE) in a breast cancer patient usually results from axillary lymph node dissection, sentinel lymph node biopsy, and/or axillary radiotherapy. Although lymphatic obstruction and consequent LE can occur due to axillary lymph node involvement, such presentation in breast cancer patients has rarely been reported. This report describes the case of a 50-year-old lady with right breast carcinoma who presented with right upper limb lymphedema. Surprisingly, she did not have any bulky axillary lymphadenopathy that could have accounted for lymphedema of the upper limb, but a suspicious breast mass was present on clinical examination. Diagnosis of breast cancer on clinical examination can be challenging in such patients due to breast edema and careful imaging of the breast and axilla with appropriate imaging tools (mammogram, ultrasound, MRI, PET mammography) should be resorted to before excluding malignancy. Lymphoscintigraphy confirmed the findings of lymphedema in the right upper limb and revealed uptake in the epitrochlear lymph nodes of the contralateral limb suggesting that she might had pre-existing widespread "subclinical lymphedema" which presented as "clinical lymphedema" in right upper limb after axillary lymph node/lymphatic involvement by right breast carcinoma.

Soft Tissue and Lower Limb Muscle Metastases from Breast Carcinoma: An Unreported Entity.

Soft tissue metastasis from carcinoma breast is rare, and still rarer is metastasis to skeletal muscles. So far, soft tissue metastasis from breast carcinoma has been reported only in a small number of case series and case reports. To the best of our knowledge, no case of breast cancer metastasizing to the lower limb muscles has been reported. It is important to differentiate soft tissue metastasis from primary soft tissue malignancy, as the management and prognosis of these differ markedly. Here, we present a case of breast cancer metastasizing to the soft tissue at multiple sites including the right thigh muscles.

Estimating the weight of consumed tobacco product waste in various Indian states: a novel method to assess the potential burden of tobacco product waste.

INTRODUCTION: The direct morbidity and mortality caused by tobacco are well documented, but such products also contribute to a range of environmental pollutants resulting from tobacco product waste. No previous studies have yet quantified tobacco product waste in a low-income and middle-income country (LMIC). This study estimates the potential annual waste generated due to consumption of smoked and smokeless tobacco products in India and its states. METHODOLOGY: We systematically collected samples of smoked and smokeless tobacco products from 33 districts of 17 Indian states/union territories. Stratified weights of plastic, paper, foil and filter packaging components, and gross empty package weights were recorded. Prevalence of smoking and smokeless tobacco use at national and state-level estimates was derived from the Global Adult Tobacco Survey (2016-2017) to quantify waste potentially generated by tobacco products. RESULTS: We included 222 brands of tobacco products (70 cigarette, 94 bidi and 58 smokeless tobacco brands) in the final analysis. A total of 170 331 (±29 332) tonnes of waste was estimated to be generated annually, out of which 43.2% was plastic, 3.6% was foil and 0.8% was filter. Two-thirds of the overall waste was contributed by smokeless products alone. Maximum waste was generated in Uttar Pradesh (20.9%; 35 723.7±6151.6 tonnes), Maharashtra (8.9%; 15 116.84±2603.12 tonnes) and West Bengal (8.6%; 14 636.32±2520.37 tonnes). CONCLUSION: This study provides first of its kind national-level evidence on the types (plastic, paper, foil and filter) and quantity of waste potentially generated by use of tobacco products in India. Similar studies from other LMICs can serve to raise consciousness about many negative environmental impacts of tobacco products and need for policies to address them.

Determinants of initiation, continuation and cessation of smokeless tobacco use among pregnant and lactating women: a qualitative study from low-income communities in urban India.

Smokeless tobacco (SLT) consumption increases the risk of cardiovascular diseases and cancer and leads to adverse reproductive health outcomes among women and newborns. This study examines the factors associated with initiation, continuation and cessation of SLT use among women in the reproductive age so as to formulate and include prevention and cessation interventions from its inception. The study was conducted in urban low-income communities in India. Using snowball and purposive sampling techniques, in-depth interviews were conducted with 20 pregnant and 22 lactating women who currently used SLT products. Data were analysed using thematic analysis with the help of QSR NVivo software. Findings revealed that factors such as people influencing usage change with different life stages including pre-marital and post-marital periods. Perceived health benefits, altered taste preferences during pregnancy and social influences were also studied. Women were found to be more aware of the harmful effects of tobacco during pregnancy than during breastfeeding. Social stigma around women consuming tobacco acted as a major driving factor for cessation. Most of the participants were willing to quit but were not aware of any technique or programme for cessation. The findings of the study highlight the need to develop behavioural change intervention tools, which are culturally and locally appropriate and have a gender-sensitive approach. Different socio-cultural factors associated with initiation/cessation at different life stages should also be taken into consideration while developing these tools.

Smokeless tobacco use and public health nutrition: a global systematic review.

OBJECTIVE: Tobacco consumption among low- and middle-income countries where food insecurity remains a challenge poses several concerns. This review examines the available global evidence linking smokeless tobacco (SLT) use with public health nutrition and its implications. DESIGN: Systematic review of articles extracted from PubMed and Scopus from January 2000 to December 2020. SETTING: Included studies that demonstrated the relationship between SLT and nutrition-related factors, that is, BMI, malnutrition, anaemia, poor birth outcomes and metabolic disorders. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines have been followed to conduct the systematic evidence review. PARTICIPANTS: A total of thirty-four studies were finally used in the systematic review, which included cross-sectional (thirty-one) and cohort (three). RESULTS: SLT use has a huge impact on body weight, alteration in taste, poor oral health, and consumption of fruits and vegetables leading to malnutrition. Maternal use of SLT not only leads to anaemia but also hampers birth outcomes. Increased risk of metabolic syndrome and gallstone disease among SLT users are also well documented in the studies. CONCLUSION: The review highlights the linkages between SLT usage and poor nutritional outcomes. Tobacco control efforts should be convergent with public health nutrition to achieve overall health benefits. Attention is also required to explore suitable mechanisms for SLT cessation combined with enhancing food and nutrition security at the community level in sync with investments in public health nutrition intervention.

Banning asbestos in talcum powder: Time for action in India.

Long-term use of asbestos-contaminated talcum power has been reported to be the main causative agent for carcinogenesis in many research studies. In recent developments Johnson & Johnson has lost multimillion-dollar lawsuits for being associated with the development of mesothelioma and ovarian cancer by its talc-based baby powder. In May 2020, the company announced, the end of the sale of its baby powder in the USA and Canada and in August 2022, announced the global discontinuation by 2023. However, in India vast proportions of people are using talc-based baby powder and the products are readily available in the market. The purpose of this communication is to create awareness and draw attention of authorities for effective regulation, including prohibition of sale and retraction of the contaminated talc-based products from the Indian market at the earliest.

Acute inflammatory response to multiple chemotherapy regimen in breast carcinoma: An unreported entity1.

Increased utilization of chemotherapy in breast cancer patients has led to improved survival outcomes but it has also resulted in rising incidence of adverse effects. Occurrence of new/unreported side effect poses challenge in front of clinicians. We report the case of a 53-year lady with locally advanced, hormone receptor-positive, and human epidermal growth factor-2 (HER-2) negative right breast carcinoma. She was started on neoadjuvant chemotherapy (NACT) (doxorubicin and cyclophosphamide), to facilitate breast-conserving surgery. She developed an inflammatory reaction involving the affected breast after each of three cycles of NACT (2 cycles of doxorubicin & cyclophosphamide, and 1 cycle of docetaxel). Infectious causes and disease progression were ruled out. She was then prescribed hormone therapy but the disease progressed after three months of therapy and the patient had to be subjected to modified radical mastectomy (MRM). She then received adjuvant radiotherapy and is currently doing well on second-line hormone therapy.

Social desirability and under-reporting of smokeless tobacco use among reproductive age women: Evidence from National Family Health Survey.

Introduction: This study hypothesises that the presence of a third person during the interaction between the survey investigator and the woman respondent leads to underreporting of smokeless tobacco (SLT) use by Indian women, including pregnant and breastfeeding women. Methods: Cross-sectional data from the National Family Health Survey conducted in 2015-16 was analysed for SLT use among women aged 15-49. Multivariate logistic regression examined the odds of SLT use reporting by women respondents in the presence of their husbands and other male or female adults. Results: SLT use reporting by women significantly varied by the presence of someone during the interview. The analysis shows that the odds of reporting SLT use among women who were neither pregnant nor lactating was 20.6% lower when they were interviewed in the presence of their husbands than when they were interviewed alone. Similarly, compared to those interviewed alone, the odds of women reporting SLT use was 16.5% lower among pregnant and breastfeeding women interviewed in the presence of any adult female. The odds of women under-reporting SLT use were higher in Central and Western India. Conclusions: This study argues that the current survey estimates misconstrue the authentic prevalence of tobacco use among women in India, including pregnant and lactating women. Due to social desirability or the presence of a third person during the survey interview, those respondents who do not report their tobacco use status are also more likely to forego essential support for successful tobacco cessation. Survey methodology must be strengthened to avert the presence of a third person during the interview to ensure better reporting and population health estimates.

Smokeless tobacco industry's brand stretching through FM radio: A study from Delhi National Capital Region, India.

Smokeless tobacco (SLT) consumption is associated with multiple adverse health effects and mortality, with the highest burden in India. The WHO FCTC has banned tobacco advertisement, promotion and sponsorship via Article 13. Indian laws also prohibit any kind of direct or indirect advertisements in all forms of audio, visual, and print media; brand promotion; and sponsorship of tobacco products. However, the tobacco industry continues to find aggressive marketing ways to advertise their products. This study aims to assess the extent of surrogate advertisement of smokeless tobacco products through frequency modulation (FM) radio stations in the city of Delhi (National Capital Territory of India). In this study, the advertisements broadcasted over FM radio across different channels (private and government owned) in total 162 h were analyzed. The time duration was spread evenly over morning peak hours, off hours, and evening peak hours. It was found that multiple brands including Vimal, Kamla Pasand, and Rajshree have used surrogate advertising to market their brands that are commonly associated with smokeless tobacco products. However, no such advertisement was found to be aired on government-owned FM channels. The total surrogate advertisements broadcasted were over 286 times, where no significant difference was found in distribution among peak and non-peak hours. The study indicated that the tobacco industry is making its way to sell the products through indirect advertisements. The need of the hour is to not only enforce tobacco advertising ban laws in all forms of advertising media but also to strictly regulate smokeless tobacco products.

Prevalence of smoking and smokeless tobacco use during breastfeeding: A cross-sectional secondary data analysis based on 0.32 million sample women in 78 low-income and middle-income countries.

Background: Smoking and smokeless tobacco use during the postpartum period is well studied in high-income countries, whereas low-income and middle-income countries (LMICs) lack evidence. Methods: In this cross-sectional study we used data from the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) conducted in 78 LMICs between January 2010 and December 2019 to study tobacco use among 0.32 million sample lactating women. Age-standardized prevalence of smoking and smokeless tobacco use was estimated and presented with a 95% Confidence Interval (CI) for 78 LMICs. Pooled estimates overall and by WHO regions were obtained using random-effects meta-analyses. Country-level and community-level variance to understand contextual factors was also quantified using multilevel modelling. Findings: Pooled prevalence of any tobacco use among breastfeeding women in LMICs was 3.61% (95% CI 3.53-3.70); with the lowest prevalence in regions of the Americas (1.44%, 1.26-1.63) and the highest in the Southeast Asia region (6.13%, 6.0-6.27). The pooled prevalence of tobacco smoking was reported to be 1.16% (1.11-1.21), with the highest prevalence in the Eastern Mediterranean region (4.27%, 3.88-4.67) and the lowest in the African region (0.81%, 0.76-0.86). The pooled prevalence of smokeless tobacco use was reported to be 2.56% (2.49-2.63), with the highest prevalence in the Southeast Asia region (4.92%, 4.80-5.04). Illiterate and poor women in LMICs bore the enormous burden of tobacco use. Interpretation: The prevalence of smoking and smokeless tobacco use among lactating women in LMICs varied considerably across different WHO regions. Considering the cross-sectional design of the study, caution is required while interpreting the results. To improve mothers' and children's health and nutrition outcomes and reduce health inequalities in LMICs, reducing tobacco use through evidence-based interventions is critical. Funding: None.

Cathepsin S as an early biomarker for cardiovascular disease in chronic kidney disease patients / Catepsina S como um biomarcador precoce para doença cardiovascular em pacientes com doença renal crônica

Abstract Introduction: A high incidence of cardiovascular disease (CVD) events and premature mortality is observed in patients with chronic kidney disease (CKD). Thus, new biomarkers that may help predict the development of CVD in early stages of CKD are being investigated along with other traditional risk factors. Objective: To investigate cathepsin S as an early biomarker for CVD in patients with CKD. Methods: A total of 64 patients with CKD were included and classified into 2 groups: CKD patients with established CVD and CKD patients with non-established CVD. All patients were submitted to routine investigations including complete blood count, random blood sugar, glycated hemoglobin (HbA1c), serum electrolytes, urea, creatinine, total protein, total albumin, calcium total, phosphorous, uric acid, vitamin D, parathormone, lipid profile, liver function test, measurement of serum cathepsin S (Cat S), and 2D Echo of the heart. Results: The level of serum Cat S was increased in CKD patients with CVD (p <0.05) as well as in later stages of CKD (p <0.05). CVD was also more common in patients in early stage CKD. In early stages CKD, Cat S and CVD were positively correlated. Conclusion: These findings suggest that serum Cat S might be useful as an early biomarker for CVD in CKD patients.

Resumo Introdução: Uma alta incidência de eventos de doença cardiovascular (DCV) e mortalidade prematura é observada em pacientes com doença renal crônica (DRC). Assim, novos biomarcadores que podem ajudar a prever o desenvolvimento de DCV nos estágios iniciais da DRC estão sendo investigados juntamente com outros fatores de risco tradicionais. Objetivo: Investigar a catepsina S como um biomarcador precoce para DCV em pacientes com DRC. Métodos: Um total de 64 pacientes com DRC foram incluídos e classificados em 2 grupos: pacientes com DRC com DCV estabelecida e pacientes com DRC com DCV não estabelecida. Todos os pacientes foram submetidos a investigações de rotina incluindo hemograma completo, glicemia aleatória, hemoglobina glicada (HbA1C), eletrólitos séricos, ureia, creatinina, proteína total, albumina total, cálcio total, fósforo, ácido úrico, vitamina D, paratormônio, perfil lipídico, teste de função hepática, medição da catepsina S sérica (Cat S), e Eco 2D do coração. Resultados: O nível de Cat S sérica esteve aumentado em pacientes com DRC com DCV (p <0,05), bem como em estágios posteriores da DRC (p <0,05). A DCV também foi mais comum em pacientes com DRC em estágio inicial. Em estágios iniciais da DRC, a Cat S e a DCV foram positivamente correlacionadas. Conclusão: Estes achados sugerem que a Cat S sérica pode ser útil como um biomarcador precoce para DCV em pacientes com DRC.