Iris Publishers- Open access Journal of Yoga, Physical Therapy and Rehabilitation | Mutation Induction, Detection and Breeding to Resist Viral and Fungal Diseases and Thermal Extremism for Vegetables

 

Authored by Yousif DP*

Opinion

To artificially induce hereditary changes in plants, either physical or chemical agents are used. Ionizing radiation is a widely used physical agent to treat the seeds and other crops plant material to create heritable mutations. On other means, one of the most important breakthroughs in the history of genetics was the discovery that mutations can be induced by physical and chemical mutagens (agents that change the genetic base of an organism). Mutation induction, together with mutation detection a key element of mutation breeding, has been an important tool for plant breeders for more than 70 years to increase the genetic diversity of plants and derive new mutant lines with improved characteristics.

Generally, mutations are a result of large-scale deletions, inversions or translocations of chromosomes, or from point mutations (a type of mutation that causes a single change, insertion or deletion of the genetic material) in the DNA. Physical mutagens most often result in chromosome changes and larger DNA deletions while mutagenic chemicals typically cause point mutations. The degree of mutation also depends on the tissue and the time and dosage of exposure. DNA mutations are generally of the most interest to breeders.

Ionizing radiation, a Physical mutagen, mostly, can increase the natural mutation rate by 1,000 to 1 million-fold, and commonly used to induce heritable genetic changes. Since the 1960s, X-ray and gamma rays with a cobalt-60 source, have become the widely used mutagenic agents in plant mutation breeding.

The next step in mutation breeding is to detect which plants have indeed produced the desired new traits. The detection of novel induced mutants presents a major challenge because it occurs with low frequencies which requires the creation of very large mutant M1 population. It is very important how-to asses and select the useful mutants that have developed a new desirable trait mutated plant.

Collaboration between the FAO and IAEA in joint projects results to develop and adopt nuclear-based technologies that optimize mutation induction practices, with the goal to intensify crop production and preserve natural resources.

Screening protocols, such as for salt and drought tolerance screening methods or disease screening protocols, are efficient methods and practical tool for mutant phenotyping detection and breeding. Recent detection technologies have increased the efficiency of identifying the DNA changes that generate a new trait. TILLING (Targeting Induced Local Lesions in Genomes), allows directed identification of mutations in a specific gene. Detection of novel induced mutations has long been a bottleneck in plant mutation breeding. Screening for desired traits in plants and section practices increased and accelerate the development of mutant lines into commercial varieties.

Mutation Breeding

Mutation breeding is the further step of mutation induction and mutation detection. It has many comparative advantages: it is cost effective, quick, proven and robust. It is also transferrable, ubiquitously applicable, non-hazardous and environmentally friendly. More than 3,200 mutant varieties – including numerous crops, ornamentals and trees – have officially been released for commercial use in more than 210 plant species from over 70 countries (FAO/IAEA Mutant Varieties Database).

Plant biotechnologies play an important role in mutation breeding. Plant tissue culture techniques are powerful tools in shortening the time needed to generate breeding mutant lines. This is a bottleneck for the exploitation of induced crop mutations that are recessive (in genetics, when one characteristic of a gene is not expressed because a more dominant one is displayed).

Project planning

Virus diseases became limited factor for vegetables production in Iraq. However, the virus host became available continuously and so causing high yield loss seasonally.

Tomato is an important crop which occupied an advanced degree in food demand all over the world and in Iraq is the first one of vegetables. There is many reasons consider a limited factor of this crop productivity. Virus infection especially Tomato Yellow Leaf Curl Virus (TYLCV) is in the present of the main problem and may lead to high or full losses of yield in some years. High temperature degree in summer which rise to about 45 -50o causes reduce flowering and fail of setting and so lead to high yield losses.

Potato also severe of many devastating virus diseases causing high productivity reduction annually, which indicates the urgent needs to reproduce of virus free tuber continuously to avoid their continuous concentration excess with successive generations. The shortage of thermal moderation period (20 -25°) which is suitable for potato growing, and tubers production beginning after one month of emergence in March to last of May in spring, and in October to half of December in Autumn cultivation.

Eggplant and pepper are important crops for food and health. Virus diseases such Eggplant and Pepper Mosaic became also a limited factor of production, in addition to the grey mold and white mold caused by the fungus Botrytis cinerae, and Sclerotinia sclerotiourum are important, especially in plastic houses. High temperature degree in summer causing to slow plant development, fruit growth, flower falling, and weak setting.

Searching for varieties or variants having resistance, or moderately resistance, or tolerance, or slow virus or fungus disease development became of high importance to avoid the negative impact of these diseases. Irradiation of seeds or tuber buds and plant tissue culture are of the important ways to induce genetic variation and developing short plant growth period or suitable for thermal extremism. This project including the following main subjects which presents the target project objectives:

• Determining of the mainly devastating virus and identification of their virulent strains.

• Testing of all available varieties of each crop to its important viruses’ strains and determines their different level of resistance, or tolerance, or slow symptoms development.

• Irradiation of seeds, or tubers, or tissue cultures of the selected varieties to induce new resistant traits and/ or new mutant cultivars.

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Iris Publishers- Open access Journal of Gynecology & Womens Health | A Nomogram for Prediction of Risk Factors for Preeclampsia during Antenatal Care at a Tertiary Maternity Hospital

 

Authored by Ahmed M Abbas*

Abstract

Objective: The study aims to create a nomogram for prediction of risk factors for preeclampsia (PE) during antenatal care (ANC) in a tertiary maternity hospital.

Materials and Methods: A cross-sectional study was conducted between May 2016 and December 2017 in a tertiary maternity hospital. Two hundred thirty pregnant women were included, at first visit, personal data, family history of risk factors for PE, maternal medical, and obstetric history was collected. Physical examination, including blood pressure, weight, signs of edema, and urine analysis were done. Then follow up at 24 weeks and after 32 weeks gestation to know if she developed PE or not through the physician. Included nomogram, which was built based on the data of regression analysis, was used to predict the value of one or more responses from a set of predictors.

Results: The study included 230 women. Cases diagnosed with PE during all the follow up are 37 cases (16.1%). Five factors were not significant; maternal age (P=0.154, OR=1.076), consanguinity (P=0.821, OR=1.104), age at marriage (P=0.266, OR=1.404), age at first pregnancy (P=0.319, OR=0.735) and order of pregnancy (3rd or more) (P=0.951, OR=0.984). Only two factors significant; a history of diabetes mellitus (P=0.010, OR=5.923) and history of hypertension (P=0.045, OR=7.838). Probability of PE based on the finding of the nomogram was 68% with good discrimination.

Conclusion: History of diabetes mellitus and hypertension were the predictors in the final model among pregnant women for the development of preeclampsia.

Keywords: Prediction; Preeclampsia; Risk factors; Nomogram

Introduction

Hypertensive disorders of pregnancy are one of the leading causes of maternal and infant morbidity and mortality. Worldwide, hypertensive disorders of pregnancy affect 5-10% of all pregnancies and cause approximately 50,000 deaths among women every year [1]. The incidence of preeclampsia (PE) is influenced by parity, racial, genetic predisposition, and environmental factors may also have a role. The incidence of PE varies greatly worldwide. World Health Organization (WHO) estimates the incidence of PE to be seven times higher in developing countries (2.8% of live births) than in developed countries (0.4%) which is due to poor healthseeking behaviours and un-availability of health care facilities and personnel [2,3].

Maternal mortality due to PE varies between (2-30%) and is much higher in rural areas. In Egypt, the prevalence of PE is (10.7%) in a community-based study while, in hospital-based studies ranged from (9.1-12.5%) of all deliveries [1,4,5].

Prevention of PE may be primary, secondary. Primary prevention involves avoiding pregnancy in women at high risk for PE, modifying lifestyles or improving nutrients intake in the whole population to decrease the incidence of the disease. Therefore, probably most of the cases of PE are unpreventable. Secondary prevention is based on interruption of known pathophysiological mechanisms of the disease before its establishment. Recent efforts have focused on the selection of high-risk women and have proposed an effective intervention, as early as it is possible, to avoid the disease or its severe complications [6].

The aim of the study was to create a nomogram for prediction of PE causing risk factors during antenatal care at a tertiary maternity hospital.

Patients and Methods

A cross-sectional study was conducted at Antenatal Care Clinic (ANC) in Assiut Women Health Hospital. This clinic is the main largest clinic in Assiut Governorate which provides antenatal care services for pregnant women.

A convenience sampling of pregnant women who attended at ANC for six months period from the beginning of May 2016 till the end of December 2016 and follow up waves ended in (March 2017). The total number of the study sample composed of 230 pregnant women was included and continued until the end of the study. All pregnant women who agree to participate in the study were included if gestational age was from 4th to 18th weeks and without mental disorders.

Two tools were utilized in the current study:

Tool 1

Structured interview questionnaire developed after reviewing the literature and previous research which were relevant to the present study, it included the following (3) parts:

Part 1: included the following:

1. Personal data scale which included: Age, name, telephone number, level of education, occupation …etc.

2. Family history of risk factors for PE such as previous PE, a family history of (diabetes mellitus, chronic hypertension, chronic kidney disease, cardiovascular diseases, thrombophilia, lupus, and smoking).

3. Maternal medical and obstetric history such as Gestational age at the beginning of the current study, consanguinity, age at marriage, age at first pregnancy, history of (preeclampsia, hypertension, diabetes mellitus.etc.).

Part 2

Physical examination of pregnant women, including (blood pressure, weight, signs of edema, and urine analysis).

During the first contact with the women that were enrolled, the physical examination (blood pressure, urine analysis, and signs of edema) was done.

Part 3

It included following up the pregnant women through three waves after the first contact with the pregnant women (4:18 weeks):

1st wave of follow up:

At the (24th) weeks of gestation, the pregnant women conducted phone calling to know the result of (blood pressure, urine analysis) and know if she diagnosed with PE or not through the physician. If the pregnant woman is diagnosed with PE will not be followed through the second wave.

2nd wave of follow up:

Before the (32th) weeks of gestation, the pregnant women conducted phone calling to know the result of (blood pressure, urine analysis) and know if she diagnosed with PE or not through the physician. If the pregnant woman is diagnosed with PE will not be followed through the third wave.

3rd wave of follow up:

After (32th) weeks, the pregnant women conducted phone calling to the result of (blood pressure, urine analysis) and know if she diagnosed with PE or not through the physician.

Tool 2

Included nomogram, which was built based on the data of regression analysis, was used to predict the value of one or more responses from a set of predictors.

The collected data were reviewed, prepared for computer entry, coded categorized, analyzed and tabulated. Data entry and data analysis were done using STATA version 12 and SPSS (Statistical Package for Social Science) version 19. Data were presented as a number, percentage, mean, standard deviation. Chi-square and Fisher Exact Tests were used to compare qualitative variables. Mann-Whitney test was used to compare quantitative variables between groups in case of non-parametric data. Regression analysis was done to rank the different risk factors of preeclampsia. P-value considered statistically significant when P < 0.05. Based on the regression analysis the probability of PE calculated through nomogram.

Results

As shown in Table 1 more than two fifths (40.9%) of the study participants aged from 25-30 years, three fifths (60%) of them were from rural area and more than one third (35.7%) of them had technical education, while (83%) of pregnant women were housewives, more than three fifths (63.9%) of them had income less than 1000 L.E and less than one third (3%) of them had consanguinity marriage.

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Iris Publishers- Open access Journal of Gynecology & Womens Health | Benign Gynecologic Surgery in the Elderly Patient

 

Authored by Juana Hutchinson-Colas*

Abstract

Benign Gynecologic surgery for the elderly patient has certain considerations for the provider to be aware of. As the population ages, more women require benign gynecologic procedures. To date, there are no guidelines regarding pre-operative, intra-operative, and post-operative care specific to this patient population. This outline provides a reference for providers when approaching the elderly patient in need of benign gynecologic surgery.

Introduction

The need for surgical treatment of benign gynecological conditions will increase as women are living longer and the incidence of pelvic floor disorders increase with aging. Pelvic floor disorders such as prolapse and urinary incontinence cause significant physical and emotional distress and sometimes require surgical management.

When preparing a patient for benign gynecologic surgery, there are certain chronic health issues to consider. For all patients, one must take into account the overall health of the patient, preoperative workup, surgery itself, and post-operative recovery. In the elderly patient, there are additional considerations to keep in mind. For many reasons including patient safety, the elderly should not be grouped into the same category as a younger, healthier patient when preparing for surgery. To date, there are no universal guidelines to assist the provider in preparing the elderly patient for benign gyn surgery. This paper outlines the pre-operative, intraoperative, and post-operative practices to optimize this surgical care.

The most common conditions for benign gynecologic surgery in the elderly population include post-menopausal bleeding, pelvic organ prolapse, urinary incontinence, and benign tumours such as persistent ovarian cysts. Surgical treatment for the above conditions include dilation and curettage, diagnostic and operative laparoscopy, vaginal and abdominal hysterectomy, laparoscopic hysterectomy, uterine/vaginal suspension procedures, vaginal obliteration, and mid-urethral retro pubic or trans-obturator slings. Most of these procedures are minimally invasive in nature or can be performed by minimally invasive techniques. According to the American College of Obstetrics and Gynaecologists (ACOG), when feasible a vaginal approach is the preferred route for hysterectomy since there are demonstrated improved patient outcomes, shorter operative time, and faster recovery. Also, vaginal approach allows for various anaesthesia techniques including regional, which is beneficial for the elderly patient. When vaginal approach cannot be achieved, laparoscopy should be considered. Both of these minimally invasive techniques are preferred over abdominal approach in the elderly population [1].

Pre-Operative

The pre-operative workup of an elderly patient undergoing benign gynecologic surgery should follow certain guidelines. As in all medical conditions, the most important first step is a thorough history and physical. Knowing the elderly patient’s medical history provides important information to be able to optimize her for elective surgery and minimize potential complications. The history of present illness, past medical and surgical history is primary areas of focus as we begin her workup.

The history of present illness lets the patient tell her story in her own words. It is essential to elicit the most bothersome symptoms since many benign gynecologic interventions in the elderly population are driven by the patient’s discomfort. Personal or familial history of thrombo-embolic events is important to consider so that deep venous thrombo-embolic prophylaxis can be offered. One important aspect of the history is the social history because many elderly depend on their family or health care proxy for immediate post op care and recovery assistance. This can identify any areas that need to be addressed before surgery, such as, social services, visiting nurses and rehabilitation facilities.

When performing a physical examination on the elderly patient, there are certain areas on which to focus. First, we note the general ambulation and nutritional status of a patient. For example, can she walk from the waiting room into the examination room? Does she need assistance with a walker or wheelchair? These initial observations give us a useful overview of the general health and performance status. The physical exam continues with a cardiopulmonary exam including heart, lung, and pulses. Next, joint mobility is determined as this may be limited in the elderly patient with history of arthritis. Joint mobility and limitation are important considerations during patient positioning in the operating room. Many gyn procedure are performed in dorsal lithotomy where hip and knee mobility, or lack thereof, can affect successful set up and surgery. Patients may need to be positioned in dorsal lithotomy prior to anesthesia induction to maximize patient comfort and safety. Throughout the history and physical examination, the neurologic status of the patient can be determined. If there is a question of the patient’s neurologic status, the mini-mental state examination, a 30-point questionnaire assessing cognitive function, can be employed. This may be helpful in determining capacity and ability of patient to fully understand informed consent.

Cardiovascular risk calculators

According to the most recent Centres for Disease Control and Prevention (CDC) guidelines, heart disease is the leading cause of death in women of all races and origins in the United States [2]. Therefore, when preoperatively evaluating the elderly gyn patient for surgery, cardiovascular risk assessment is essential. There is several cardiovascular risk calculators used preoperatively to predict certain cardiac events.

The revised cardiac risk index (RCRI) by Lee et al. has been validated and used for over 20 years to assess preoperative cardiac risk. The RCRI takes into account the patient’s history, current medical health condition, and type of surgery to stratify patient’s risk for a cardiac complication during a non-cardiac surgery. This tool provides the health care provider with the risk of a cardiac complication and can assess the need for further cardiac testing, but it does not identify non-cardiac risks for patients [3]. Another method is the National Surgical Quality Improvement Program (NSQIP) risk prediction calculator, which has been validated in over 1.5 million patients. This web-based decision-support tool estimates risk to patient and has proven accuracy in predicting morbidity and mortality [4]. Based on one of the above risk calculators, a provider will obtain a risk of cardiovascular event for a patient. If the risk is <1%, the patient is considered to be low risk and no further cardiac workup is needed. If the risk score is >1%, then the patient is considered higher risk and further testing may be necessary.

High risk cardiac patients should be considered for further cardiovascular evaluation. The 2014 American College of Cardiology/American Heart Association (ACC/AHA) is an important guide to determine the functional status of a patient. If she is able to complete four or greater metabolic equivalents (METS) without symptoms, no further cardiac testing is needed. For example, if she can climb one flight of stairs without shortness of breath, she may not need a comprehensive cardiac workup. If she is unable to do so, additional testing should be ordered [5].

Diabetes

In the elderly population, diabetes is a common condition that should be addressed since perioperative hyperglycaemia poses a significant infection risk and can delay wound healing. Elective surgery should only be performed when the patient’s HgbA1C is below 7 as this has been proven to decrease postoperative wound infection [6]. In addition, patients with a history of diabetes are also at increased risk of coronary heart disease, hypertension, obesity, all which increase perioperative risk. Early surgical start time (before 9AM) may present an additional advantage to the diabetic patient and minimizes disruption of management of glucose control.

Medications

A complete review of all medications both prescribed and over the counter is important. Some medications should be discontinued weeks before surgery, while others should be continued until the morning of the procedure. For patients with hypertension, beta, alpha and calcium channel blockers should be continued as prescribed and taken the morning of surgery with a sip of water. In particular, stopping beta blockers prior to surgery has proven to increase cardiac morbidity and mortality [7-9]. Because of the risk of rebound hypertension with acute cessation of alpha-2 blockers such as clonidine, these medications should also be continued pre-operatively. Continuing calcium channel blockers during perioperative period has no proven contraindications.

Angiotensin-converting enzyme (ACE) inhibitors and angiotensive-2 receptor blockers (ARBs) are common antihypertensive that should be used with caution preoperatively. Patients taking either ACE inhibitor or ARB in combination with a diuretic are at risk for intraoperative hypotension [10]. Therefore, these medications should not be taken the morning of surgery. ACE inhibitors, ARBs, and diuretics may be resumed within 48 hours postoperatively. Patients taking statins should continue this therapy. In fact, in one international prospective cohort study, the use of statins in patients undergoing non-cardiac surgery was associated with a lower risk of cardiovascular outcomes 30 days after surgery [11]. However, no studies exist that suggest starting routine statin use in a patient not already using this medication.

Women who are taking hormone replacement therapy (HRT) are encouraged to stop prior to surgery. HRT increases the risk of venous thromboembolism (VTE), and since surgery alone also increases this risk, the compounded effect of HRT in a surgical patient should be avoided [12]. Many women on HRT are perimenopausal or at the start of menopause. The elderly patient population is usually not on HRT, so this becomes less of a consideration. On the other hand, selective estrogen receptor modulators (SERM) may more commonly be used in the elderly gynecologic population in treatment of breast cancer (tamoxifen) or osteoporosis (raloxifene). SERMs increase the risk of VTE and care must be taken prior to surgery. Raloxifene should be stopped 3 days prior to surgery. Tamoxifen as a breast cancer prevention strategy should be stopped 2 weeks prior to surgery. However, when tamoxifen is being used for breast cancer treatment, one can consider continuation of the drug with additional measures for VTE prophylaxis [13].

Prevention VTE

All surgical patients are risk stratified for risk of VTE. The American College of Chest Physicians Caprini score is universally used as a preoperative assessment tool for VTE during surgery and guides intra-operative prevention. Women aged 61-74 years old receive 2 points on the risk score model, while women aged 75 years and older receive 3 points. Other points that apply to the elderly gyn population include cancer, prior VTE, estrogen use, smoking, and obesity. Low risk patients (Caprini score 1-2) have 1.5% estimated baseline risk of VTE should have mechanical prophylaxis during surgery. Moderate risk patients (Caprini score 3-4) should have intermittent pneumatic compression device applied and can be considered for chemical prophylaxis with low molecular weight heparin or low dose unfractionated heparin if they do not have a bleeding risk. Finally, high risk patients (Caprini score greater than or equal to 5) have a 6% estimated baseline risk of VTE and should receive chemical VTE prophylaxis intraoperative in addition to mechanical prophylaxis [14].

Informed consent

Informed consent begins with a discussion regarding the nature of the patient’s problem and degree of bother. It continues with reviewing treatment options and desired outcomes. Once preoperative assessment is completed, a surgeon is better able to provide the patient with specific benefits and risks of various treatment options. Having a family member present for preoperative consent can be helpful for the patient in recalling the discussion and the salient points critical to informed consent. Also, the pre-operative visit can be an overwhelming experience for any patient. Being accompanied by a trusted confident, family member or friend may alleviate some anxiety while providing a personal witness to the conversation. We encourage having a family member or care provider present because they will also be involved in perioperative instructions and post-op care.

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Iris Publishers- Open access Journal of Annals of Public Health & Epidemiology | Farmer’s Response to Tobacco Processing Company in Tobacco Cultivation in Bangladesh

 

Authored by Khan Mehedi Hasan*

Abstract

Several tobacco processing companies patronize tobacco cultivation in Bangladesh. The major objective of the project was to assess farmers’ response against the strategies of tobacco companies in the Jhenaidah district of Bangladesh. Farmers’ perceptions were taken through focused group discussion. Tobacco companies’ activities and strategies were discussed initially. After that, farmers’ reactions on companies’ strategies in both positive and negative directions were analysed in the context of traditional agriculture of the district. Tobacco companies’ sales guarantee at prefixed price motivated farmers to go for contract with tobacco cultivation. Tobacco company provided full revenue at a time which was another point of motivation for tobacco cultivation that was not generally observed in other crops. Though cost of cultivation from tobacco was very high, it provided higher profit in compared with other crops cultivated in the tobacco season. Some crops provided higher profit than tobacco but those were not guaranteed in every season due to high price fluctuation. Companies input support free of cost and at loan but was repaid after harvest attracted many famers into tobacco. In addition to these company supported incentives, farmers considered the option of using family labor, and unique features of tobacco like high cash crop, safe from disease as motivation for cultivating tobacco. Farmers’ negative considerations over tobacco companies were high charge for inputs, subjective grading system of cured tobacco, less address of health safety issues, wide range of hidden and unaccounted cost associated with tobacco cultivation. Non-guaranteed sales and unstable price were main challenges for traditional crops in the district for which tobacco companies’ offers become lucrative to cultivate tobacco. As tobacco is the substitute to the food security of the overburden people of Bangladesh, the research suggests making control over tobacco companies by limiting quota on acres of land to be contracted for tobacco and forcing companies to internalize all health and environmental related costs. Farmers’ awareness need to be created by assessing and publicizing all the unaccounted cost components associated with tobacco farming. At the same time, it is essential to assure sales of general crops at stable price.

Keywords: Contract farmer; Deforestation; Tobacco curing; Tobacco processing company; Sales guarantee

Introduction

Background of the study

Tobacco started to replace general crops in Bangladesh in the mid-sixties of the last century. The process was speeded up by the British American Tobacco (BAT) in Teesta silt in the Rangpur area after liberation in 1971. The study of PROGGA [1] showed that tobacco was grown in 70,000 hectares in the last season of 2013. In that year about 38,000 hectares of additional land was used than the year 2012, 108,000 hectares of land was cultivated for tobacco in 2014. The largest tobacco growing areas of the country include Rangpur, Kustia and Chittagong Hill Truck [2]. In addition to converting new land under tobacco, new farmers are also entering tobacco cultivation in each year, though there is skipping tendency too. The shares of tobacco in GDP value and employment have also increased in several years in recent decades.

Table 1 shows that the growth rate of both area and production was very high for all years from 2002-03 to 2011-2012. Production growth can be explained by HYV, but area growth is clearly alarming and a threat to food security. The share of GDP value of tobacco manufacturing was 5.44 percent in 1996-97 in all manufacturing while it increased to 6.22 percent in 2004-05.

Chart 1 shows that both tobacco production and land under tobacco production were almost stable from 1995 to 2008. After that both showed an upward jump. Land for tobacco was being retained or increased over time where total agricultural land gradually decreased in Bangladesh.

Apart from processed tobacco exports from Bangladesh, domestic tobacco is used as input of bidi, cigarettes, and other semi-processed tobacco products. Many tobacco companies have established semi-processing units near the tobacco growing regions. In the country, bidi manufacturing annual employment amounts to 621,000 labour with 155,000 direct labour and 466,000 indirect labour [3]. Tobacco companies across Asia and Africa get engaged with tobacco farmers for getting assurance about the target amount of tobacco. As a component of the contract, companies provide different inputs and technical support free of cost or at loan. Support normally includes high inputs like seeds, fertilizers, chemicals and other production implements during cultivation and the curing stage. Farmers are contracted to sell a certain amount of tobacco to these companies. In this way companies avoid intermediaries to collect tobacco leaves and thus become able to reduce tobacco procurement costs [4]. Moreover, contract farming allows companies to control tobacco variety, volume, production costs, and creates asymmetric bargaining powers between tobacco firms and farmers [5].

Diverse factors, including region specific factors are liable for spreading tobacco cultivation. Naher and Chowdhury [6] pointed out that family labour, guaranteed sales and ready cash attract farmers to cultivate tobacco. Akhter [7] found that high profit, cash earning, guarantee of inputs and guarantee of sale, play roles in continuing tobacco cultivation. Tobacco companies move in different regions for mining fertile soils. Van Minh et al. [8] showed that in rural Vietnam the average tobacco farmer gets a greater financial benefit from tobacco cultivation than other crops. Furthermore, the myopic view of the farmers about the immediate gain from tobacco cultivation is blamed for expansion of tobacco culture. There is causality between low education level (not completed primary level) of children and tobacco growing of most of the farmers that grow tobacco [9].

It is proved in scientific research that tobacco consumption causes diverse health problems. Globally about 63 percent of all deaths are caused by non-communicable diseases, among which tobacco products are considered one of the major risk factors. Mortality as well as morbidity is increased by tobacco smoking. Both tobacco production and supply are a cause for increased tobacco consumption. Globally, about 600,000 people die from second-hand smoking exposure each year. Among these deaths, the large majority occur in densely populated underdeveloped countries [10]. In Bangladesh, about 58 percent of men and 29 percent of women consume any sort of tobacco, either smoked or smokeless [11]. A significant number of people from Bangladesh are at great risk of use of tobacco products, especially smoking tobacco. Easily availability of tobacco products in Bangladesh is a liable factor which is linked to tobacco production. Over time, tobacco production is increasing in Bangladesh. The [12] identified tobacco-related illness for Bangladesh.

Tobacco cultivation has tremendous social and health bearing which goes often unnoticed. Tobacco farming requires large amounts of wood for a variety of purposes, such as curing, and poles and sticks for barn construction. Tobacco growers cut homestead forests or purchase wood to cure tobacco which creates huge pressure on forest resources [13]. The study of Siddiqui and Rajabu [14] showed that, on average, 4 kg of fuel wood is consumed to obtain 1 kg of cured tobacco. Those who have direct involvement in tobacco cultivation and processing suffer from various health problems. The victims of this health risk include children, pregnant women and older people who participate in tobacco production or live near tobacco-growing fields [15]. Many dimensions of social and environmental costs of tobacco cultivation are grossly unaccounted. For instance, tobacco cultivation puts constraints on other crop farming, adversely affects land fertility and creates external costs on health hazards. Child involvement in tobacco cultivation also leads to increased school drop-out rates.

Many farmers observed a decline in soil fertility for long term tobacco cultivation in the same land which caused lower yield in other crops too. After adding the opportunity cost of family labour, Van Minh H [8] found very minimal profit for one region and negative for another region in Vietnam. There exists some anti-social movement in some regions in Bangladesh where some regions also showed growing interest for tobacco. Sometime farmers partially shifted from tobacco production due to government initiatives to get farmers back into food crop production. Some farmers stopped cultivation completely. At the same time many remained in cultivation but reduced the amount of land for tobacco cultivation. Some farmers continued and some also entered tobacco cultivation. Though Bangladesh is an agrarian economy, it is characterized with many limitations. In that case, farmers try to find crops which have less challenge in the input and output market. It is urgent to examine the reasons why conventional agriculture (mostly crop agriculture) fails to arrest the increased adoption of tobacco culture. As tobacco is a socially undesirable product, there is a need to discourage farmers. In order to prescribe some policies, it is essential to identify the dynamics among traditional crops, tobacco companies and tobacco farmers. Unless tobacco production is reduced, it would be hard to reduce food insecurity and public health risk. Withdrawing poor farmers from tobacco cultivation is not an easy task. In order to minimize tobacco cultivation, the first step would be exploring the tobacco firm-farm linkage. Along with exploring the strategies of tobacco companies, it is equally essential to identify factors that influence farmers to adopt, continue or to quit tobacco in the context of traditional agriculture. It will help to understand how tobacco companies are defining strategies to encourage tobacco cultivation. This research will contribute to policymaking as it is blamed that there is no direct policy to regulate tobacco cultivation in Bangladesh [1]. This research output will give a clear direction for designing a participatory tobacco control policy in Bangladesh.

Objectives of the research

The research firstly aimed to explore strategies of tobacco companies that support tobacco cultivation. Main research questions were to explore how do tobacco companies implement their strategies and what package they offer to farmers. Second objective of the research was to identify farmers’ responses to tobacco companies’ strategies. In this case, research questions were to know why some farmers decide to be contracted with tobacco companies and what benefit and cost do they consider. This research question helps in understanding the role of various supports from tobacco companies to arrest the expansion and adoption of tobacco cultivation by farming households. At the same time, it will help to stereotype farmers who want to be engaged in tobacco cultivation and to what extent. And third objective was to explore the context of traditional agriculture and compare those in the context of tobacco and tobacco companies. Research questions posed in this research was to explore why some farmers prefer tobacco cultivation over traditional crop agriculture while others do not do so. This research question helps to understand the strengths and challenges of tobacco over tradition crop cultivation.

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Iris Publishers- Open access Journal of Otolaryngology and Rhinology | A Rare Case of Mixed Tumor of Right Nasal Sill Diagnosed Histopathologically more Frequently than Expected

 

Authored by Tan Shi Nee*

Abstract

Mixed tumor (MT) is an unusual, benign skin appendageal tumor, with an eccrine and apocrine origin, resembling mixed tumors of the salivary glands. Although it usually involves the head and neck region, the nasal region is a rare location. It develops as a slow-growing, small cutaneous mass. We report a rare case of mixed tumor in a 35-year-old female, who presented with a firm, asymptomatic mass in the right nasal sill, slowly growing for approximately 5 years. A provisional clinical diagnosis was made by fine needle aspiration cytology evaluation. The final diagnosis is confirmed by histopathological examination. This case highlights the importance of fine needle aspiration cytology in providing the essential clue to uncover the diagnosis and orient the surgical management of the patient. The excision and repair techniques require more skill and time, considering the location of the lesion.

Keywords: Chondroid syringoma; Mixed tumor; Pleomorphic adenoma; Fine needle aspiration cytology; Skin adnexal tumors

Introduction

Mixed tumor (MT) is an unusual, rare benign skin appendageal tumor with an eccrine and apocrine origin, resembling mixed tumors of the salivary glands. It was first described by Hirsch and Helwig which was previously named as Chondroid Syringoma (CS) due to the presence of sweat gland elements in the cartilaginous stroma [1]. The incidence of the mixed tumor is low (about 0.01% reported) [2, 3]. It usually involves the head and neck region developing as a slow-growing, small cutaneous mass. Because of its non-specific presentation and rare incidence, the diagnosis of MT is usually made by the histopathologic report [3]. Herein, we report a case with a histologically proven mixed tumor of the nasal sill. The review of the literature on this topic (mixed tumor located in the nasal region) is extremely limited in this manuscript.

Case Presentation

A 35-year-old female with unremarkable medical history presented with a mass located in the right nasal still that had been developing for 5 years. The swelling started as small and slowly progressing nodule (Figure 1). The swelling was not painful and no other tumors were noted elsewhere. There was no history of trauma or spontaneous bleeding. No history was suggestive of systemic illnesses. Local examination revealed a firm to hard mass measuring about 2x2.5cm situated over the right nasal sill. It was mobile, non-fluctuant, non-tender fixed to the skin, and freely mobile over the underlying structure. No regional lymphadenopathy was observed. A provisional diagnosis of the right nasal sill sebaceous cyst was made. The fine needle aspiration cytology performed before operation suggested a benign lesion where there are clusters of spindle cells that have oval nuclei with an abundance of well-defined cytoplasm and are embedded in a chondromyxoid substance.

Our patient underwent an excisional biopsy of the right nasal sill mass with histopathological examination. Grossly, the excised tumor mass with attached elliptical superjacent skin measured 4 x 2.5cm. Its external surface was smooth (Figure 2). Microscopically, the section showed an intradermal, thin encapsulated circumscribed tumor tissue composed of a mixture of an epithelial and mesenchymal component which suggestive of more eccrine origin. The epithelial components consist of ductal and myoepithelium. The ductal epithelium lined the ducts and composed of rows of cuboidal cells. Post-operative, the procedure was uneventful (Figure 3). On 2nd and 6th month follow-up in the outpatient clinic, the patient was well, with excellent wound healing and no complications or local recurrence.

Discussion

Mixed tumor (MT) is a rare tumor which is also known as chondroid syringoma. Hirsch and Helwig first introduced the term CS [1]. It is later introduced bu Virchow and Minssen [4] of the new term, mixed tumor of the skin because it represents benign tumor with the cutaneous (epithelial) part and mesenchymal in origin [5].

Five histological criteria were proposed to diagnose chondroid syringoma for these tumors, by Hirsch and Helwig in 1961 [1]:

1) Interconnected tubuloalveolar structures which were lined with two or more rows of cuboidal cells.

2) Nests of cuboidal or polygonal cells.

3) Ductal structures which were composed of one or two rows of cuboidal cells.

4) Occasional keratinous cysts.

5) A matrix of varying composition

CS may have all the five histological criteria or they may have only one characteristic.

As a rare entity, the mixed tumor may not typically be part of the differential diagnosis of a slow-growing subcutaneous mass in this region. From a histopathological perspective, its differentiation towards various skin adnexal structures which include hair follicle, apocrine, sebaceous gland, and hair matrix may not always be apparent and it may be confused with other more common skin lesions of epidermal or mesenchymal appendages such as a dermoid cyst, sebaceous cyst, epidermal cyst and neurofibroma, lipoma, etc [6].

Fine needle aspiration cytology (FNAC) is a good guide as initial planning of diagnostic purpose and it may be useful to determine possible pathology before excision [7]. However, most of the time, histopathological examination of the surgical specimen is key to establishing a correct and complete diagnosis of CS. Besides that, mixed tumor or known as chondroid syringoma share similarities with pleomorphic adenoma. The differences between both are, pleomorphic adenoma is a mixed tumor that arises from salivary glands and chondroid syringoma are mixed tumor arise from the sweat glands [6, 8].

Most of the time, the usual clinical presentation is that of an asymptomatic slow-growing mass in the region of the head and neck. In our case, the tumor is located in the right nasal sill, and our patient presented to the clinic because of aesthetical concerns. Other consequences of the slowly growing mass over the nasal site are nasal obstruction, aesthetically disfigured, pain, and risk of infection. Presently, there is a multitude of treatment options for chondroid syringoma such as carbon dioxide laser (CO2 laser), electrodesiccation, and vaporization with argon or CO2 laser [8]. However, complete surgical excision with negative margins is the preferred treatment choice [3, 6] to prevent a high rate of recurrence.

Such treatment options were preferred surgical excision because they are safe, without adverse scarring, textural changes, an aesthetically and functionally reliable method that can eradicate the tumor. The tumor clearance rate increased as complete surgical excision is possible. Hornick and Fletcher reported a series of 33 cases of benign low-grade cytology where they showed a total of 6 patients (18%) that developed local recurrence, however, there were no clinical or histologic features reported with the recurrence [9]. A study done by Hornick and Fletcher was done to characterize this tumor further and they showed that although the majority are a morphologically benign myoepithelial tumor of soft tissue or mixed tumor, there is still a risk for local recurrence. In our case, the location of the tumor in the right nasal sill was a challenge, as we were not only aiming to perform a complete excision with negative margins but also careful to preserve the aesthetics and functionality of the affected structures. It is also important to closely follow-up the patient because of the risk of local recurrence [10].

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