Biomedical subjects
Publications and source records attributed to P C Gupta.
Reports from India showing comparatively lower prevalence rates of oral leukoplakia and lower malignant transformation rates than in western countries appear paradoxical because of high incidence rates of oral cancer in India. On a closer examination of available data however, it becomes clear that there is no inconsistency.
The occurrence of central papillary atrophy of the tongue among tobacco users, its clinical characteristics and the long term behavior in relation to changes in tobacco use was studied in 182 individuals in Ernakulam district, Kerala, India. Almost all (98%) lesions occurred among bidi smokers. Clinically, about 31% occurred in combination with bidi smoking associated lesions such as palatal erythema (14%), leukoplakia (8%) or both (3%). Histologic evaluation in 12 biopsies using single PAS stained sections showed candidal hyphae in 67%. A 10-yr follow-up (mean: 6.7 yr) of the 182 lesions showed that the regression was highest (87%) among those who stopped their smoking habit and persistence among those who did not reduce or stop their smoking habits. The findings from this study confirm a strong link between bidi smoking and central papillary atrophy of the tongue in rural Indian populations.
Immunoglobulins profile was carried out in 60 cases of measles (30 each with and without complications) and 30 age and sex matched controls. Antibody titres and immunoglobulins levels (IgG, IgM and IgA) were determined by hemagglutination inhibition and single radial immunodiffusion techniques, respectively. Though higher IgG and IgM levels were found in complicated cases compared to controls, more importantly lower IgA levels were seen in these cases. As most of the measles complications are secondary bacterial infections of mucosal surfaces, it is postulated that these patients might have been selected for a relatively severe form of the disease due to either a pre-existing or induced IgA deficiency.
Seven cases of benign form of spinal muscular atrophy were studied to evaluate the importance of detecting hand tremors, muscle fasciculation, evertion of foot and ECG tremors to distinguish these cases from muscular dystrophy. Taken in combination, diagnosis of all the seven cases was possible without the need for application of more sophisticated and invasive investigations, e.g., EMG, nerve conduction study, CPK levels and muscle biopsy.
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Regional variations in the characteristics of submucous fibrosis were studied in two districts in India. In Pune district this condition involved soft palate, uvula and retromolar areas significantly more often than in Ernakulam district. The tongue, floor of the mouth and the hard palate were not involved in Pune. The age of the patients in Pune district was lower than in Ernakulam district. Associated oral cancer, leukoplakia and petechiae were observed solely among patients in Ernakulam. The most important etiologic factor for submucous fibrosis is the chewing of areca nut, and in both areas studied all patients chewed areca nut. In Pune, cured areca nut without other ingredients was chewed by 66% and in Ernakulam, raw areca nut was chewed as an ingredient of pan with tobacco by 100%. Thus in Ernakulam, the juice and the quid were mostly spat out, whereas in Pune they were swallowed. The regional variations in the characteristics of submucous fibrosis could be related to the differences in the areca nut chewing habit between the two areas.
In a house-to-house survey, 36 471 tobacco chewers and smokers were selected from the rural population in three areas of India. These individuals were interviewed for their tobacco habits and examined for the presence of oral leukoplakia and other precancerous lesions, first in a baseline survey, and then annually over a 5-year period. By personal advice and via the mass media they were encouraged to give up their tobacco habits. The follow-up rate was 97%. The control cohort was provided by the first 5-year results from a 10-year follow-up study conducted earlier in the same areas with the same methodology but on different individuals without any educational intervention. In Ernakulam district (Kerala) and Srikakulam district (Andhra) substantially more people stopped their tobacco habit and reduced the frequency of tobacco use in the intervention cohort than in the control cohort; in Bhavnagar district (Gujarat) the intervention group showed only a slightly higher proportion stopping their tobacco habits and no difference in the proportion reducing them. The 5-year age-adjusted incidence rate of leukoplakia in Ernakulam district was 11.4 in the intervention group versus 47.8 among men, and 5.8 versus 33.0 among women; and for palatal lesions in Srikakulam district the corresponding figures were 59.8 versus 260.8 among men and 289.5 versus 489.5 among women. In Bhavnagar the incidence rate of leukoplakia did not differ between the cohorts. Since most oral cancers are preceded by precancerous lesions, education on tobacco habits should be a feasible and effective approach to primary prevention of oral cancer.
The malignant potential of oral lichen planus was assessed on the basis of observations in 722 patients found among 27,599 individuals examined in various epidemiologic studies in Kerala, Ernakulam district, India. Seven hundred and two patients with oral lichen planus were re-examined annually over a 10-year period with a mean observation period of 5.1 years. Most of the lesions (93%) were observed among tobacco users. Carcinoma developed in 3 (0.4%) patients with oral lichen planus. Clinically, all 3 had atrophic components in their lesions, and all were tobacco users. The relative risk of a lichen planus developing oral cancer compared to a tobacco user was estimated as 3.3. However, this relative risk was not significant. Histologically, 74% of the 94 biopsies from oral lichen planus showed epithelial atrophy. Two of the 3 in whom cancer developed also showed epithelial atrophy. It is felt that epithelial atrophy probably renders the mucosa more vulnerable to the carcinogenic action of tobacco. Although this study could not confirm the precancerous nature of this disease with a high degree of certainty, the disease did not appear to be innocuous either.
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In a house-to-house screening survey, 12,212 tobacco chewers and smokers were selected from the rural population in the Ernakulam district, Kerala state, India. These individuals were interviewed for their tobacco habits and examined for the presence of oral cancer and precancerous lesions, first in a baseline survey, and then annually, over a five-year period. They were educated using personal and mass media communication to give up their tobacco habits. The control group was provided from the results of the first five years of a 10-year follow-up study conducted earlier by the authors in the same area with the same methodology but on different individuals without any educational intervention. The stoppage of the tobacco habit was substantially higher in the intervention group (9.4%) compared to the control group (3.2%). A logistic regression analysis showed that the behavioural intervention was helpful to all categories of individuals, however, the effect was different for different categories: intervention was more helpful to men, chewers, and those with a long duration of the habit. These individuals rarely quit their habit without intervention.
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In the rural health care delivery system in India, basic health workers (BHW) go house-to-house to help in the preventive and therapeutic measures of certain diseases. Some 53 BHW were trained by the dentists of the research team for examining the oral cavity of high-risk individuals and categorizing them into normals or those with referable or nonreferable lesions. Referable lesions comprised nodular leukoplakia, submucous fibrosis, and ulcers and growths suggestive of oral cancer. In a 1-year period, 39,331 high-risk individuals were examined by BHW and 523 (1.3%) were referred for further diagnosis. Some 72% arrived at the referral center and 20 oral cancers were confirmed among these individuals. Reexamination in the field by the dentists was conducted for 5% of the sample to obtain sensitivity and specificity estimates of BHW diagnosis. The findings indicate that incorporation of an oral cancer detection program in the existing health care infrastructure is feasible and beneficial.
Sixty-six patients with oral submucous fibrosis were followed-up for a period of 17 yr (median observation 10 yr) in Ernakulam District, Kerala, India. Oral cancer developed in five (7.6%) patients. The malignant transformation rate in the same sample was 4.5% over a 15-yr observation period (median 8 yr). These findings impart a high degree of malignant potential to this condition.
A 10 year follow up study was performed of tobacco usage and oral disease in a random sample of 10 169 persons in Srikakulam district between 1967 and 1976. Age adjusted mortality rates in those who indulged in reverse smoking of chuttas (coarse cheroots) were nearly twice those of non-users of tobacco. Oral cancer explained only a small fraction of the excess mortality but reliable information was not available for other causes of death.
In a house-to-house survey in Ernakulam district, Kerala, India, 12,213 tobacco users were interviewed about the details of their tobacco usage and examined for the presence of leukoplakia. The frequency of tobacco habit was associated with the prevalence of leukoplakia indicating a positive dose-response relationship. The dose-response relationship remained significant, taking age, sex, and the type of tobacco habit into account. After adjusting for all these variables jointly the association still remained significant. The dose-response relationship was stronger for the smoking habit than for the chewing habit. A weaker relationship in the chewing habit was not due to the duration of chewing habit or the habit of retaining the betel quid in the mouth while sleeping. Thus the dose-response relationship, although significant, was different for tobacco smoking and chewing habits.
Five children presented with focal seizures and neurological deficits that progressed over a span of months to years. Three had temporal lobectomy to control seizures, one underwent temporal lobe biopsy, and the fifth, who suffered from immunodeficiency, had an occipital lobectomy to remove a mass. Two of the children expired. Neuropathological findings in all five children were consistent with a persistent active "viral" encephalitis. No infectious agent was identified. None of the children had the usual systemic signs of encephalitis and all lacked an inflammatory response in their cerebrospinal fluid. We conjecture that this condition may be more frequent than realized. Besides causing intractable focal seizures and hemiparesis, it may account for other poorly understood syndromes of childhood with deteriorating behavior.
Mortality experience of a cohort of 10 287 individuals age 15 years and over selected by random sampling in Ernakulam district of Kerala was recorded in house-to-house surveys over a 10-year period. Mortality rates were analysed according to tobacco habits of chewing and smoking, taking-age and sex distribution into consideration. Tobacco chewing was practised most commonly by females and these females had significantly higher age-adjusted mortality rates than those who did not use tobacco (relative risk 1.3). Excess mortality among male bidi smokers (relative risk 1.5) was also significant and comparable to the excess mortality among cigarette smokers reported from Western countries.
In a house-to-house survey in Ernakulam district, Kerala State, 10914 individuals were interviewed for their tobacco and alcohol habits and examined for the presence of oral leukoplakia. Very few females (1.6%) were found to be alcohol users and they were excluded from further analysis. Among 7604 males, 30.4% used alcohol regularly, 25.4% occasionally and 44.2% were non-users. The prevalence of leukoplakia was significantly higher among regular (5.7%) and occasional (3.9%) users than among non-users (2.9%) of alcohol. Alcohol usage was found to be related to age as well as tobacco habits. The prevalence of leukoplakia was higher among alcohol users in each age-group as well as in each tobacco habit category. After age-adjustment the difference between alcohol users and non-users, although reduced, remained significant. For most tobacco habit categories the trend remained similar after age-adjustment except for the mixed habits group, for which there was a reversal of the trend. The alcohol habit may, perhaps, produce discernible effects only in association with other 'weak' etiological risk factors, such as a single tobacco habit of smoking or chewing rather than a 'strong' etiologic factor such as the mixed habits of chewing and smoking.