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Lakshmi Int J Med Res Health Sci. 2015;4(3):477-482

International Journal of Medical Research

&

Health Scienceswww.ijmrhs.com Volume 4 Issue 3 Coden: IJMRHS Copyright @2014 ISSN: 2319-5886Received: 20th April 2014 Revised: 10th Jan 2015 Accepted: 18th April 2015

Research article

A COMPARATIVE STUDY OF ORAL OLANZAPINE AND ORAL HALOPERIDOL ON GLUCOSE

TOLERANCE LEVELS IN PATIENTS WITH SCHIZOPHRENIA

*G N S Sangeetha Lakshmi

Asst Professor, Dept of Pharmacology, Osmania University, Hyderabad

*Corresponding author email: [email protected]

ABSTRACT

Background: Schizophrenia is a mental disorder characterized by persistent defects in the perception, thinking or

the expression of reality. The term "schizophrenia" translates roughly as "shattered mind," and comes from the

Greek (schizo, "to split" or "to divide") and ( phrēn, "mind"). Material and Methods: The study was designed to

be a prospective control study. Schizophrenic patients taking Olanzapine and Haloperidol were selected and

follow up at three weeks and six weeks was done. Results: In this prospective control study, Olanzapine and

Haloperidol were associated with an increase in Blood Glucose Levels. The mean changes in Glucose remained

within clinically normal range in this six week study. Conclusion: Antipsychotic treatmemt leads to the

development of Diabetes mellitus in a significant 10.1% of patients within 6 weeks. Given the serious

implications for morbidity and mortality attributable to diabetes mellitus, clinicians need to be aware of these risk

factors when treating patients with chronic schizophrenia

Keywords: Schizophrenia, Olanzapine, Haloperidol, Blood Glucose levels

INTRODUCTION

Schizophrenia is often described in terms of

"positive" and "negative" symptoms. Positive

symptoms include delusions, auditory hallucinations

and thought disorder and are typically regarded as

manifestations of psychosis. Negative symptoms are

so named because they are considered to be the loss

or absence of normal traits or abilities, and includefeatures such as flat, blunted or constricted affect and

emotion, poverty of speech and lack of motivation.

Some models of schizophrenia include formal

thought disorder and planning difficulties in a third

group, a "disorganization syndrome."[1]

The most commonly used criteria for diagnosing

schizophrenia are from the American Psychiatric

Association's Diagnostic and Statistical Manual of

Mental Disorders (DSM) and the World Health

Organization's International Statistical Classificationof Diseases and Related Health Problems (ICD). The

most recent versions are ICD-10.[2]

Cause: Genetic: Some researchers estimate

schizophrenia to be highly heritable (some estimates

are as high as70%). Environmental[3]

- There is also

considerable evidence indicating that stress may

trigger episodes of schizophrenia psychosis.

Neurobiological influences: Role of dopamine: In

adult life, particular importance has been placed uponthe function (or malfunction) of dopamine

[4]in the

mesolimbic pathway in the brain. This theory, known

as the dopamine hypothesis of schizophrenia, largely

resulted from the accidental finding that a drug group

which blocks dopamine function, known as the

phenothiazines, reduced psychotic symptoms. These

drugs have now been developed further and

antipsychotic medication is commonly used as a first

line treatment. Role of glutamate and the NMDA

receptor: Interest has also focused on theneurotransmitter glutamate and the reduced


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Olanzapine and controls took oral Haloperidol along

with their concomitant treatment.

After the patients fulfilled the inclusion criteria,

Random Plasma Glucose was taken before the start of

treatment patients who had above normal random

blood glucose (Normal RBS-120-140 mg/dl.) were

not taken into the study.

After the patient was started on an antipsychotic i.e.

in the first week, Blood was taken for Fasting Blood

Glucose and Post Prandial blood glucose. When the

patient came for review after three weeks and again

after six weeks fasting blood glucose and post

prandial blood glucose was taken. At each visit 2ml

Blood was taken under aseptic conditions. From the

blood sample sent to the laboratory, serum was

separated immediately after clotting.

Fasting blood glucose and post prandial blood

glucose was estimated by standardized enzymatic

procedure (applying glucose oxidase – peroxidase

method). Enzymatic method yields maximum

specificity for the procedure. From the blood sample

sent to the laboratory, serum was separated

immediately after clotting. Samples were used on the

same day. Haemolysed or grossly contaminated

samples were not used.

The following reference values were used in the

Laboratory.

Random Blood Sugar = 120 – 140 mg/dl.

Fasting Blood Sugar = 60 – 90 mg/dl.

Post prandial blood sugar = 140 – 160 mg/dl.

RESULTS

Basic Description of Data: A total of seventy

patients who satisfied the inclusion criteria and who

signed the consent form were selected for the study.

Seven patients were lost in the follow up. The

remaining sixty three patients constituted the main

study group. The Olanzapine study group had 38

subjects (n=38) and the Haloperidol control group

had 25 subjects (n=25).

The mean age of study group was 34.5 ± 9.9 years.

The mean age of Olanzapine group was 33.1 ± 9.8

and the Haloperidol group was 35.6 + 10 years(Table

I). The Olanzapine group had Male 22 (57.9%) and

female 16 (42.1), Haloperidol group had male 11

(44%) and female 14 (56%). The Olanzapine group

had 5 subjects (13.2%) with family history of

Diabetes Mellitus and Haloperidol group had 5

subjects (20%) with family history of Diabetes

Mellitus. There was no statistical difference with

regard to family history of Diabetes Mellitus between

the two groups. When Chi square test was done, p

was 0.500 (P


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Table2: Comparison between Olanzapine and Haloperidol groups Student Independent‘t’ test

Blood Glucose Time PointOlanzapine

Mean ± SD

Haloperidol

Mean ± SDP Valve

Fasting Blood

Glucose

1st week 78.1 ± 17. 84.1 ± 19.2 0.211 (NS)

3rd week 84.8 ± 17.0 88.8 ±17.2 0.372 (NS)

6th week 88.3 ± 16.7 95.0 ± 17.9 0.132 (NS)

Increase in Fasting

Blood Glucose

1st week & 3rd week 6.7 ± 7.7 4.7 ±12.8 0.434 (NS)1st week & 6th week 10.2 ± 7.6 10.9 ± 14.0 0.805 (NS)

3rd

week & 6th week 3.5 ± 5.7 6.2 ± 6.1 0.068 (NS)

Post Prandial

Blood Glucose

1st week 108.7 ± 22.0 113.7 ± 31.9 0.465 (NS)

3rd week 115.2 ±23.3 117.3 ± 23.7 0.728 (NS)

6th week 121.3±23.6 126.8 ± 29.9 0.420 (NS)

Increase in Post Prandial

Blood Glucose

1st week & 3rd week 6.5 ±9.7 3.6 ± 18.9 0.429 (NS)

1st week & 6th week 12.6 ± 7.4 13.1 ±24.5 0.922 (NS)

3rdt week & 6th week 6.1 ± 9.8 9.5±12.5 0.236 (NS)

P < 0.05 Significant; NS-Non Significant

There is no statistically significant difference between

Olanzapine and Haloperidol group for Fasting blood

glucose and post prandial blood glucose between 1st

and 3rd

week, 1st

and 6th

week and 3rd

and 6th

week.

Significant increase in Blood glucose was seen in the

Olanzapine group. In Fasting Blood Glucose, the

significant increase for 1st and 3rd week was

P=0.001, for 1st & 6th week was P=0.001 and for 3rd

and 6th week was P=0.003.In Post Prandial Blood

Glucose the significant increase for 1st & 3rd week

was P=0.001, 1st & 6th week was P=0.001 and 3rd &

6th week was P=0.001

Table3: Comparison of Blood Glucose within

Olanzapine Group n=33 (between 1st, 3rd and 6th

week) Students Paired‘t’ Test

Blood

Glucose

(mg/dl)

Time Point Change

Mean±SD

P Valve

Fasting Blood

Glucose

1st and 3rdweek 6.7± 7.7


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Fig1: Mean change in Fasting Blood Glucose

between different time interval for Olanzapine

and Haloperidol group.

Fig2: Mean change in Post Prandial Blood

Glucose between different time interval for

Olanzapine and Haloperidol group.

The relevant findings of the study are

Olanzapine produced significant increase in

fasting blood glucose and Post Prandial blood

glucose at 3rd week and 6th week

Haloperidol produced significant increase in

fasting blood glucose and Post Prandial blood

glucose at 6th week.

When Olanzapine and Haloperidol groups were

compared there was no statistically significant

difference between the increase in fasting and Post

Prandial blood glucose.

DISCUSSION

There is a re-emerging and controversial issue of

glycaemic control in schizophrenia and its possible

relationship to antipsychotic drug therapy. Obesity

and physical inactivity, which are common in patients

with schizophrenia, are known to increase the risk of developing diabetes. It is reported a rate of diabetes

of 1.2% for persons age 18 to 44 years and 6.3% for

persons age 45 to 64 years. In patients with

schizophrenia, the prevalence of diabetes was 6 to 8%

in patients65

years of age.[12]

Case reports have also associated atypical

antipsychotic agents with exacerbation of pre-existing

diabetes, new-onset diabetes and diabetic

ketoacidosis (DKA).[13, 14]

There are significantly

more reports associated with olanzapine.

In a pharmacoepidemiological study in >58,000

patients receiving a single antipsychotic, the overall

frequency of diabetes was about 3 times that found in

the reference general population. This result is very

similar to that found in studies to determine the rate

of diabetes in patients with schizophrenia done prior

to the widespread use of atypical agents.

In this report we are comparing the simultaneous

effect of two antipsychotic medications on a

important metabolic measure, indexing glucose in

patients with schizophrenia. We found that

haloperidol was associated with significantly elevated

mean glucose levels after 6 week of treatment, that

olanzapine was associated wtih significantly elevated

glucose levels after 3 weeks of treatment. The mean

increases were modest and remained within clinically

normal ranges (one patient given Haloperidol

developed abnormally high glucose levels >125

mg/dl during the course of study treatment). The

Olanzapine-treated groups had significant elevations

in post prandial glucose levels when compared with

haloperidol-treated patients. Among antipschotics,

Olanzapine seems to have diabetogenic potential

when measured from baseline to endpoint.

Haloperidol fares better.[15, 16]

In our study, the typical antipsychotic haloperidol

was associated with an elevation of Blood glucoselevels within a clinically normal range. Haloperidol

has been reported to increase insulin resistance and to

be associated with higher fasting glucose levels in

obese women compared with control subjects.

Haloperidol has also been reported to be associated

with higher glucose levels in schizophrenia subjects.

Increased insulin resistance in peripheral tissues can

be caused by hyperprolactinemia and may be

involved in the mechanism underlying hyperglycemia

in patients treated with typical antipsychotics.


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Limitations:

• Short follow up.

• Confounding variables of co-medications.

• Short duration requires 6th month or 1 year

follow up study.

More specific test can be used like HydroxylatedHaemoglobin A (HbA) which will give the blood

glucose level for the previous 6 weeks.

CONCLUSION

In this prospective study, Olanzapine and Haloperidol

were associated with an increase in Blood Glucose

Levels. The mean changes in Glucose remained

within clinically normal range in this six week study.

Given the concerns regarding endocrine

dysregulation in the context of treatment of schizophrenia patients with antipsychotic medication

the baseline and 6th

week monitoring of fasting

blood glucose and post prandial blood glucose levels

be obtained in routine clinical practice with both

antipsychotics in order to monitor the risk for

development of hyperglycaemia.

Given the serious implications for morbidity and

mortality attributable to diabetes mellitus, clinicians

need to be aware of these risk factors when treating

patients with chronic schizophrenia.

Acknowledgement: I thank the Director of Institute

of Mental Health,Chennai,Dr.Murugappan and the

staff for helping me to do this study.

Conflict of interest: Nil

REFERENCES

1. Kraepelin, E. Text book of psychiatry (7th ed).

London : Macmillan, 1970; 525-20.

2. Turner, T. 'Schizophrenia'. A History of ClinicalPsychiatry, London,1999; 10

thedition;110-50

3. Buse JB, Cavazzoni P, Hornbuckle K.

Antipsychotic induced type 2 diabetes: evidence

from a large health plan database. J Clin

Epidemiol; 2002;167-70

4. Uvnas-Moberg K, Ahlenius S, Alster P. Effects

of selective seratonin and dopamine agonists on

plasma levels of glucose, insulin and glucagon in

the rat. Neuroendocrine logy.1996;63:269-274

5. Leucht S, Wahlbeck K, Hamann J, Kissling W.New generation antipsychotics versus low

potency conventional antipsychotics: a systematic

review and meta-analysis. Lancet,

2004;361(9369), 1581-9.

6. Weyer C,Hanson K,Bogardus C,Pratley RE.Long

term changes in insulin action and insulin

secretion associated with gain ,loss regain and

maintainance of body weight Diadetologia.2000;

36-46

7. Martin Dale Extra Pharmacopenia; 38th

edition;

675-12.

8. Newcomer JW, Haupt DW, Fucetola,et

al.Abnormalities in glucose regulation during

antipsychotic treatment of Schizophrenia.Arch

Gen Psychiatry.2002;337-45.

9. Canadian Psychiatric Association. Canadian

clinical practice guidelines for the treatment of

schizophrenia, 1998; 43:255-05.

10. Lindenmayer JP, Patel R. Olanzapine-induced

ketoacidosis with Diabetes Mellitus Am J

Paychiatry.1999; 156:1471.

11. Pharmacoepidemiol Drug Saf. 2005 Mar 22. e J

Clin Psychopharmacol. 2005; 25(1):12-8.

12. Canadian Diabetes Association 2003 Clinical

Practise Guidelines for the Prevention and

Management of Diabetes in Canada,2003;27:51-

52

13. Lindenmayer JP, Patel R. Olanzapine-induced

ketoacidosis with diabetes mellitus Am J

Psychiatry. 1999;156:1471

14. Mukherjee S, Decina P, Bocola V, et al. Diabetes

mellitus in schizophrenic patients. Compr

Psychiatry. 1996; 68-73.

15. Saddicha, ManjunathaN, AmeenS, Akhtar.S.

Diabetes and Schizophrenia-effect of disease or

drug?Results from a randomised, double blind

controlled prospective study in first episode

Schizophrenia ;2000.

16. Ramaswamy K, Masand PS, Nasrath HA.Docertain atypical antipsychotics increase the risk of

diabetes? A Critical review of 17 Pharmaco

epidemiologic studies Ann ClinPsychiatry.2006;

18: 183-94.


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Mindolli et al., Int J Med Res Health Sci. 2015;4(3):483-485

DOI: 10.5958/2319-5886.2015.00093.4


&

Health Scienceswww.ijmrhs.com Volume 4 Issue 3 Coden: IJMRHS Copyright @2014 ISSN: 2319-5886

Received: 25th Oct 2014 Revised: 10th Nov 2014 Accepted: 13th Nov 2014Research article

SEROPREVALENCE OF HEPATITIS B IN A TERTIARY CARE CENTRE IN BIJAPUR,

KARNATAKA: A TWO YEARS PROSPECTIVE STUDY

*Preeti B. Mindolli1, Manjunath P. Salmani

2

1Associate Professor, Department of Microbiology, Al Ameen Medical College, H &RC, Athani Road, Bijapur,

Karnataka, India.2Associate Professor, Department of Microbiology, SBMP Medical College, H &RC, Solapur Road, Bijapur,

Karnataka, India.


ABSTRACT

Background: Hepatitis B virus infection is endemic throughout the world especially in tropical and developing

countries. Clinical data collected in the hospital gives the estimation of burden of disease in the community as

patients with different background attend the hospital. With this background the present study was designed. It is

a prospective study estimating the prevalence of HBV infection in a tertiary care centre. Objective: Study was

conducted to know the prevalence of hepatitis B virus infection in a tertiary care centre in Bijapur, Karnataka.

Methodology: Patients attending Out-Patient Department (OPD) and In-Patient Department (IPD) with various

diagnosis who were advised for HbsAg testing were included in this study. Immunochromatographic method(Hepacard) was used for qualitative detection of HbsAg to diagnose HBV infection. Results: A year wise

seropositivity showed there was slight increase in the HBV positive cases. In 2012 prevalence rate was 1.54% and

in 2013 it was 1.65%. Male preponderance compared to females was seen. More number of cases was seen in

active age group i.e. 31-40 years. Conclusion: The present study shows there is slight increase in number of cases

in 2013 compared to 2012. This study also highlights that hospital based studies can be an option for community

based studies.

Keywords: Hepatitis B; Immunochromatography; Seroprevalence

INTRODUCTION

Hepatitis B virus (HBV) is common human pathogenand causes acute and chronic liver disease throughout

the world. Chronic illness develop in 5-10% 0f

infected adolescents or adults and up to 90% in

infected neonates. Chronic HBV infection is a major

cause of liver cirrhosis and primary cell carcinoma.[1]

Hepatitis B is endemic throughout the world,

especially in tropical and developing countries and

also in some regions of Europe. Its prevalence varies

from country to country and depends on behavioral

environment and host factor.[2]

More than two billion people worldwide haveevidence of past or current HBV infection and 350

million are chronic carriers of the virus, which is

harbored in liver and causes an estimated 6, 00, 000

deaths from cirrhosis of liver and hepatocellular

carcinoma.[3]

In Middle East and Indian subcontinent, an estimated

2-5% of general population is chronically infected

and falls in intermediate category according to World

Health Organization (WHO) classification.[2,3]


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Year Total No.

of cases

Total No. of

HBsAg positive

Total

positive (In

%)

2012 8944 138 1.54%

2013 9428 156 1.65%

Sex No. of

sera

tested

Total No. of

HbsAg positive

Total positive

(In %)

Male 9,268 159 1.71%

Female 9,104 135 1.48%

Several surveys for HbsAg screening have been

carried out at different places for blood donors,

pregnant women. Surveys for screening HBsAg have

been primary, simple and most useful mode for

determining HBV infection rate.[4]

MATERIALS AND METHODS

Source of data: The study group comprises of

patients of all age groups and both sexes admitted

during January 2012 to December 2013 in IPD of all

departments of Shri B.M. Patil Medical College,

Hospital and Research Centre, Bijapur, Karnataka.

Type of study: Prospective analysis

Ethics committee approval: The study was

approved by the Institutional Ethics Committee

(IEC).

Methodology: Two ml of blood sample was collected

with aseptic conditions. The serum was separated

and it was used for the present study. Specimens

containing visible precipitates or cloudy specimens

are clarified prior to testing by high speed

centrifugation i.e. 10,000 revolutions per minute for

fifteen minutes before testing. The test was performed

within twenty four hours from the sample collection.

For qualitative detection of HbsAg, test was done by

Immunochromatographic method (Hepacard) to

diagnose HBV infection performed and test card was

labeled with identification number[5]

. The test was

performed and interpreted according to

manufacturer’s instructions. The kit has sensitivity

and specificity of 100%.

Data collection: Patients personal details like age,

sex, address was noted down. The HBsAg test result

(positive or negative) was noted of individual person.

The collected data is represented in tabular form and

prevalence rate was calculated. The speed, sensitivity,

ease to perform and interpret the results makes itmore useful for both individual as well as large scale

studies.[5, 6]

RESULTS

The study was conducted from January 2012 to

December 2013. A total of 18, 372 samples were

screened for HbsAg during this period and year wise

prevalence rate was calculated.

From January-December 2012, 8,944 samples were

screened, out of which 138 were positive andprevalence rate was 1.54%. From January-December

2013, 9428 samples were screened out of which 156

were positive and prevalence rate was 1.65%.

There is slight increase in prevalence rate in 2013

compared to 2012 (Table 1).

Male preponderance is seen compared to females

(Table 2).

Increased prevalence of HBV infection is seen in 31-

40 years age group followed by >50 years age group

(Table 3).

Table 1 Seropositivity of HbsAg among hospital

based population

Table 2: Sex distribution of seropositivity of

HbsAg in hospital based population

Table 3: Age distribution of hospital based general

population for HbsAg postivity

Age

(Years)

Total No.

of sera

tested

Total No.

of HbsAg

positive

Total

positive (In

%)

0-10 820 08 0.97%

11-20 2727 40 1.46%

21-30 4040 65 1.60%

31-40 4632 84 1.81%

41-50 3932 59 1.50%

>50 2221 38 1.71%

DISCUSSION

In our study of hospital based population the

prevalence rate of HbsAg in year 2012 was 1.54%

and in 2013 it was slightly increased to 1.65%. This

may be due to increased awareness about HBV

infection and number of samples to be tested has also

increased.

Similar studies on prevalence of hepatitis B are

conducted in India. A study conducted by Singh et al

among blood donors in Mangalore showed

prevalence as 0.62%.[7]

Another study conducted by

Ronald Roche et al in Mangalore in 2012 showed

prevalence rate of HbsAg as 1.56%.[8]

According to


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WHO definition one could categorize Karnataka into

a HBV low endemic state.

Another review of hepatitis B prevalence in India by

Lodha et al has concluded that it is between 1-2%.[9]

Smita sood and Shirish malvankar have noted 0.87%

prevalence which is hospital based study similar to

us.[10]

A study conducted by Bhatta CP et al in

Kathmandu Medical College teaching hospital in

2003 showed prevalence rate of HbsAg as 2.5%.[11]

Our study has reported higher prevalence among

males (1.71%) compared to females (1.48%).

Many studies shows male preponderance compared to

females. Dutta et al reported 35.3% in males and

19.3% in females.[12]

Singh et al reported 0.65% in

males and 0.25% in females. Higher prevalence

among males is also noted in Smita Sood et al

study.[10] It is hypothesized that females clear HBV

more efficiently compared to males.

In our study higher prevalence rate was seen in the

age group of 31-40 years followed by > 50 years.

Similar findings were noted in Smita Sood et al

study10

. This may be due to higher chances of

exposure to HBV infection due to sexual activity.

CONCLUSION

The present data is limited to patient population

served by our hospital and not applicable to other

centers. Hospital based studies can be alternate option

to community studies which are difficult to conduct.

The present study provides good reference to

formulate strategies to reduce the seroprevalence rate.

The patient attending our hospital represents cross

section of Bijapur district population with mix of rich

and poor and urban and rural population. Therefore

our study highlights HBV infection rate of this part of

state and shall provide reference for future studies on

epidemiology of HBV infection.

REFERENCES

1. Brian WJ. Hepatitis B. In: Topley andWilson's Microbiology and MicrobialInfections: 10

thedn Vol 2 London: Arnold

Publishers; 2005 :12262. Park K. In: Park ’s textbook of Preventive and

Social Medicine.21st

ed. Jabalpur, India: M/sBanarasidas Bhanot Publishers; 2011: 231-32

3. WHO (2009), Weekly epidemiologicalrecords, N 040, 2nd Oct 2009.

4. Sayed A. Quadri, H.J. Dadapeer, K.

Mohammed Arifulla and Nazia Khan.

Prevalence of Hepatitis B Surface Antigen in

hospital based population in Bijapur,

Karnataka. Al Ameen J Med Sci 2013; 6(2)

:180-82.

5. Kaur H, Dhanao J, Oberoi A. Evaluation of rapid kits for detection of HIV, HbsAg and

HCV infections. Indian J Med Sci 2000; 54:

432-34.

6. Torlesse H, Wurie IM, Hodges M. The use of

immunochromatography test cards in the

diagnosis of hepatitis B surface antigen

among pregnant women in West Africa. Br J

Biomed Sci 1997; 54 (4): 256-59.

7. Sing K, Bhat S, Shastry S. Trend in

seroprevalence of Hepatitis B virus infection

among blood donors of coastal Karnataka.

Indian J Infect Dev Ctries 2009; 3 (5): 376-

79.

8. Ronald Roche, Shriyan Amrita, Leslie,

Ranjana Nayak. Prevalence of the Human

Immunodeficiency Virus, the Hepatitis B

Virus and the Hepatitis C Virus among the

Patients at a Tertiary Health Care Centre: A

Five Year Study. Journal of Clinical and

Diagnostic Research. 2012 May; 6(4): 623-

26.9. Lodha R, Jain Y, Anand K, Kabra SK,

Pandava CS. Hepatitis B in India: A review

of disease epidemiology. Indian Pediatr

2001: 38: 1318-22.

10. Sood S and Malvankar S. Seroprevalence of

Hepatitis B surface Antigen, Antibodies to

Hepatitis C virus and Human

immunodeficiency virus ina Hospital based

population in Jaipur, Rajasthan. Indian J

Community Med 2010; 35 (1): 165-69.

11. Bhatta CP, Thapa B, Rana BB.Seroprevalence of Hepatitis B in Kathmandu

Medical College teaching hospital.

Kathmandu Univ Med J 2003; 1: 113-16.

12. Dutta S, Shivanand PG, Chatterjee A.Prevalence of hepatitis B surface antigen andantibody among hospital admitted patients inManipal. Indian J Public Health 1994; 38:108-12.


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Sharayu et al., Int J Med Res Health Sci. 2015;4(3):486-489


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Health Scienceswww.ijmrhs.com Volume 4 Issue 3 Coden: IJMRHS Copyright@2014 ISSN: 2319-5886

Received: 25th Dec 2014 Revised: 20th Feb 2015 Accepted: 26th Apr 2015

Research article

HISTOPATHOLOGIC AND CYTOMORPHOLOGIC CORRELATION IN LEPROSY

*Sharayu A Sarode1, Anil T Deshmukh

2

2HOD,

1Department of Pathology, Panjabrao Deshmukh Medical College, Maharashtra, India


ABSTRACT

This study was conducted in Dr. Panjabrao Deshmukh Medical College we tried to evaluate and compare the

histological and cytological procedure for classifying leprosy lesion. Method: Total sample size was 60.Skin

punch biopsy was done and sample was evaluated for histology after H & E and Fite Faraco staining. In some

cases where histological diagnosis was confirmed we also took sample for cytology which were stained by MGG

and modified ZN technique. Results Our study group consists of total 60 leprosy patients, out of which 34

(56.66%) were males and 26 (43.44%) were female between 10 years to 68 years of age. Complete

cytohistological correlation was seen in 36 (60%) cases. Correlation was fairly strong in polar group of leprosy

like in TT i.e. (62.5%) and LL (60%). Conclusion In cases of polar leprosy cytological diagnosis parallels

histological diagnosis, within the constraint of cytological interpretation the cases in borderline unstable spectrum

of leprosy can be classified broadly. Histopathological correlation is required to determine appropriate position in

RJ spectrum. Similarly in cases where aspirate was inadequate histology is required to confirm or rule out type of

leprosy.

Keywords: Tuberculoid Leprosy, Borderline Tuberculoid, Borderline Lepromatous, Lepromatous Leprosy.

INTRODUCTION

Leprosy is one of the oldest disease known to

mankind. Currently The Ridley-Jopling (RJ)

classification currently in use for classifying leprosy

is based on widely acknowledged clinical,

bacteriological, immunological, and histological

parameters.[1]

Application of the RJ scale in the

classification of leprosy helps in understanding the

immunology of the patient to predict prognosis and

possible complications. Histopathology is considered

to be a gold standard for diagnosing leprosy but it is

an invasive procedure and leads to a biopsy scar,

which may not be cosmetically acceptable. Slit skin

smear technique stained with Ziehl-Neelsen (ZN) is

considered as a simple field procedure for the

diagnosis of leprosy but many practical problemsaffect the reliability of skin-smears.

[2, 3, 4, 5,6,7]This

present study was undertaken to evaluate and

compare the histological and cytological procedure

for classifying leprosy lesion.

MATERIAL AND METHODS

Present study was undertaken in department of

pathology, Dr Panjabrao Deshmukh Memorial

Medical college after receiving clearance from

institutional ethical committee. Study done over a

period of 2.5 years from June 2011 to Oct. 2013. All

the new clinically suspected cases of leprosy

attending Dermatology OPD in Dr PDMM College

were enrolled. Informed consent was taken from

patients. Histologically confirmed cases of leprosy

were enrolled into the study.

Skin punch biopsy was performed by dermatologist.Biopsy material was immediately fixed into 10%

formalin. After adequate fixation for 10 – 12 hours

DOI: 10 5958/2319 5886 2015 00094 6


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sample was submitted for routine processing,

following which paraffin embedded section of 5 µm

thickness were stained with H and E for

histopathological analysis and fite faraco staining for

identifying bacilli. After studying histopathological

feature & noting bacteriological index the diagnosis

of leprosy was confirmed & classified as per Ridley

jopling classification.

For cytology sampling procedure depend on type of

lesion. Slit skin smear was done in cases of flat lesion

& FNA or Cytopuncture was done in case of nodular

lesion, slides were air dried and stain with May

Grunwald Giemsa stain & modified Ziehl-Neleson

stain for acid fast bacilli. Cytological procedure were

consider adequate if the cellular yield of

inflammatory cells was heavy or when eccrine sweat

glands were seen in presence of low inflammatory

cells. Cytological criteria for classifying the cases is

shown in table 1

Table 1: Cytomorphological features in leprosy[5]

Types of leprosy Morphological features

Cellularity Granuloma lymphocytes AFB

Tuberculoid

leprosy (TT)

Cellular smear Cohesive granuloma

consists of epitheloid

cell & lymphocytes

Numerous lymphocytes

not infiltrating granuloma

AFB 0

Borderline

tuberculoid(BT)

Fairly cellular Poorly cohesive

granuloma composed

mixture of epitheloid

cell and macrophages

Few lymphocytes AFB 1+,2+

Borderline

lepromatous (BL)

Moderate

cellularity

Singly dispersed

macrophages no

epitheloid cell

Numerous lymphocytes AFB 3+,4+

Lepromatous

leprosy (LL)

Heavy

cellularity

Numerous foamy

macrophages

Few lymphocytes AFB 5+,6+

RESULTS

Our study group consists of total 60 leprosy patients,

out of which 34 (56.66%) were males and 26

(43.44%) were female between 10 years to 68 years

of age. majority of patients 18 (30%) were between

age group of 20 to 29 years.12 patients (20%) were

involved in farm related activity either they were

labour or farmer.

Majority of female patients 20 (33.33%) were

housewife. 6 patients (10%) in our study were

baggers they were detached from family because of

leprosy stigma.

Out of 60 cases of leprosy, on histology majority

25/60 (41.66%) were of borderline tuberculoid

leprosy followed by tuberculoid leprosy 16/60

(26.66%). Borderline lepromatous leprosy was seen

in 3 (5.0%) cases.

There were 10/60 (16.66%) cases of lepromatous

leprosy. We also found 1 case of indeterminate

leprosy, 2 cases of histoid leprosy and 3 cases of

ENL.

All cases (16/16) of histologically confirmed

tuberculoid leprosy were paucibacillary whereas

24/25 (96.0%) cases of borderline tuberculoid leprosy

were paucibacillary. All the cases of BL and LL were

multibacillary leprosy.

There were 2 cases of histoid leprosy all were

multibacillary. Out of 3 cases of ENL 2 were

paucibacillary and 1 case was multibacillary whose

bacillary index was more than 1+.

Complete cytohistological correlation was seen in 36(60%) cases. Correlation was fairly strong in TT

leprosy i.e. (62.5%), borderline (50%), LL (60%). 2

cases of TT on cytology showed feature suggestive of

BT. 1 case of Histologically confirmed LL showed

feature suggestive of BL on cytology.

Two smears one each of TT and BT showed chronic

inflammatory cells on cytology. Remaining 24

smears for cytology were inadequate for

interpretation (table 2)


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Table 2: cytohistological correlation along RJ spectrum

Histological

classification

Cytological classification

classification No. of

cases

TT Borderline

(BT,BL)

LL Histoid ENL Indeterminate Chronic inflammatory

cells

TT 16 10 2 -- -- -- -- 1

BT 25 01 14 -- -- -- -- 1BL 3 -- -- -- -- -- -- --

LL 10 -- 1 6 -- -- -- --

Histoid 2 -- -- -- -- -- -- --

ENL 3 -- -- -- -- -- -- --

Indeterminate 1 -- -- -- -- -- -- --

Total 60 11 17 6 0 0 0 2

DISCUSSION

In present series of 60 cases we found more no of

cases in age group of 20 – 29 years around 30%. We

could not found single case below 10 years of agesimilarly in other studies also incidence of leprosy

below 10 years of age was very low[2,3,4,5,6]

. Probable

cause for this finding may be long incubation period

of leprosy[7, 8]

. Histology is considered to be a gold

standard for diagnosis of leprosy. In present series of

60 cases we did biopsy from lesion site from every

case.

The most commonly encountered type of leprosy was

BT 41.66% (25/60). Second common type was TT

26.66% (16/60), BL was seen in 5% of cases.Borderline group constituted the major spectrum

46.66% 28 biopsies, which include BT, BB, BL. A

sizeable portion of leprosy patient will be in a

continuous changing immunological spectrum i.e.

BT, BB, BL so majority of cases belong to borderline

group[8]

. According to many observer features of both

tuberculoid and lepromatous leprosy can occur in

same section or in serial sections or in different lesion

of same borderline cases immunological instability in

this borderline cases make them move in either

direction along the borderline spectrum. With

treatment they move toward tuberculoid pole or

without treatment they tend to move towards

lepromatous pole. If the disease is recognized at an

earlier stage and biopsy is taken, it will be in BT

stage or if disease is recognized at latter stage and

biopsy is taken, it may be in BL stage[9]

.

In our study overall cytohistological correlation was

seen in total 60% (36/60) cases, Cytohistological

correlation was more prominent in polar group of

leprosy. In TT leprosy 62.5% (10/16) cases were

diagnosed on cytology whereas 60% (6/10) cytology

showed feature suggestive of LL type.

Cytohistological correlation was around 50% (14/28)

borderline group of leprosy.

Slit skin smear for AFB have conventionally been

used in assessing bacteriological index in leprosy.

Marine Ridley examined cellular exudates in slit skin

smear by ZN technique for AFB this generate more

information about leprosy lesion than only BI and MI

alone. She suggest that by studying nature of

exudates it was possible to place lesion in its

approximate position of RJ scale however she failed

to differentiate epithelioid cells from macrophages or

comment on cohesiveness of granuloma. This is alimitation of ZN stain which does not provide

morphological detail comparable to that with MGG.

In present study cytological sub classification of

Histologically diagnosed leprosy was done on RJ

spectrum as per the criteria led down by ridley and

also the one adapted by N singh et al. Cytological TT

is characterized by cohesive epithelioid granuloma

with lymphocytes not infiltrating the granuloma as

the disease progress toward the lepromatous pole

cohesion between the cells of granuloma diminishes,concurrent with increasing infiltration of lymphocytes

within them thus epitheloid granuloma of TT

transform to macrophage granuloma of LL with

heavy bacterial load. This is similar to feature

described in histology. The largest no of lymphocytes

are seen in BL leprosy where these predominate cell

type[7]

.

Histological criteria for diagnosis of leprosy is

applicable to cytological smear even though nerve

damage could not be detected on cytology the overallcytodiagnostic accuracy of skin lesion has been 60%


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489


in present study this is lower than 76.6% as reported

by Singh et al[10]

. We observed uniform

cytohistological correlation in leprosy skin lesion.

However cytologic feature in cellular exudates may

be similar across Borderline tuberculoid (BT),

borderline borderline (BB), Borderline lepromatous

(BL) area.

Out of 10 cases of LL on MGG stain foamy

macrophages were seen in 6 cases i.e. 60%. 1 case of

LL was diagnosed as borderline on cytology and

remaining three smears were inadequate. Thus

complete cytohistological correlation was achieved in

60% cases of LL.

A 14 (50%) out of 28 (25 BT + 3 BL) cases were

diagnosed as borderline group mostly BT because it

shows inflammatory cell with few epithelioid cell.

Out of remaining 14 cases 7 showed nonspecific

inflammatory cells, 6 were inadequate and 1 case was

diagnosed as TT.

10 cases 62.5% out of 16 cases were diagnosed as TT

on cytology, 2 cases were diagnosed as BT, 1 showed

nonspecific inflammatory cells and remaining 3

inadequate smears.

It thus become evident that cytological examination

of cellular exudates from leprosy skin lesion provides

information similar to one obtained on histological

preparation of skin biopsy in cases of polar leprosy of

either type. In borderline cases however keeping in

view the recommendation on cytological

interpretation of a leprosy skin lesion made by

Marine Ridley[10]

can be placed broadly in BT, BB,

BL area of spectrum. It seems, in such a cases,

histologic confirmation to place the cases in

appropriate borderline group is required.

CONCLUSION

In conclusion cytomorphology study of leprosy using

MGG and Z-N Stain for AFB can act as a useful

adjuvant to histopathology. In cases of polar leprosy

cytological diagnosis parallels histological diagnosis

within the constraint of cytological interpretation the

cases in borderline unstable spectrum of leprosy can

be classified broadly. Histopathologic correlation is

required to determine appropriate position in RJ

spectrum. Similarly in cases where aspirate was

inadequate histology is required to confirm or rule out

type of leprosy.

ACKNOWLEDGEMENT: None

Conflict of Interest: Nil

REFERENCES

1. Jopling WH, McDougall AC. Definition,epidemiology and world distribution. In: Jopling

WH, McDougall AC, editors. Handbook of

Leprosy. 5th

ed. New Delhi: CBS Publishers;

1996; 1.

2. Sehal VN,SinghJ.Slit skin smear in leprosy.int J

Lepr 1990; 29:1

3. Thenvent, miyazaki, Rosche P,ShresthaI.

Cytological needle aspiration for diagnosis of

pure neural leprosy. Indian j lepr 1996; 6(5):1

4. Kaur S,Kumar B,Gupta SK,fine needle aspirationof lymphnode in leprosy.a stdy of bacteriological

and morphological indices.Int j of lepr 1971; 45:4

5. TS Jaswal,VK Jain,Vandana Jain,Manmeet

Singh,Kamal Kishor,Sunita Singh. Evaluation of

leprosy lesion by skin smear cytology in

comparison to histology. Indian jor of

pathol.microlbiol 2001; 44:3

6. Georgiev, G. D. and McDougall, A. C. Skin

smears and the bacterial index (BI) in multiple

drug therapy leprosy control programs: an

unsatisfactory and potentially hazardous state of

affairs. Int. J. Lepr. 1988; 56 101-04.

7. WHO, World Health Organization Expert

Committee on Leprosy. Sixth report, 1988. 768

8. Thangasay RH, Yawalkar SJ. Historical

Background. In: Leprosy for Medical Practioners

and Paramedical Workers. Basle: 1986; 5: 14.

9. Pandya SS. Leprosy Control in India – Historical

Aspects. In: Valia RG, VAlia AR, editors,

Textbook and Atlas of Dermatology. Bombay:

Bhalani Publishing 1994; 1422-1426.

10. Charles K. Job, Joseph Jayakumar, Michael

Kearney and Thomas P. Gillis Transmission of

Leprosy: A Study of Skin and Nasal Secretions of

Household Contacts of Leprosy Patients Using

PCR Am J Trop Med Hyg 2008 ;78(3): 518-21


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Fathima et al., Int J Med Res Heath Sci. 2015;4(3):490-495


&

Health Sciences

www.ijmrhs.com Volume 4 Issue 3 Coden: IJMRHS Copyright @2015 ISSN: 2319-5886Received: 27

thJan 2015 Revised: 25

thMarch 2015 Accepted: 9

thMay 2015

Research article

PREVALENCE AND AT EARLY AGE ONSET OF HYPO AND HYPERTHYROIDISM IN POST-

IODIZATION ERA: A HOSPITAL BASED STUDY FROM SOUTH INDIA

Fathima Nusrath1, Baderuzzaman

2, Anees Syyeda

2, N Parveen

4, Siraj M

3, N, *Ishaq M

1

1Department of Genetics, Osmania University, Hyderabad-500 007, Telangana, India

2Department of Biochemistry,

3Department of Medicine, Princess Esra Hospital,

4Salar-E-Millat Sultan Salahuddin

Owaisi Centre for Cellular and Molecular Medicine, PEH, Deccan College of Medical Sciences, Kanchanbagh,Hyderabad, Telangana, India


ABSTRACT

Background: Thyroid dysfunction has been considered as one of the most common endocrine disorder in clinical

practice throughout the world. Its increasing prevalence had led to the screening of general population in different

parts of the world in order to investigate causes for rising incidence. A nationwide survey on epidemiology of

thyroid dysfunction in selected cities of India suggested the need for further studies in order to have a more

comprehensive analysis of epidemiological aspect for better awareness and control of this endocrine disorder.

Aim: The major objective of the present study was to identify the prevalence and early age at onset of hypo and

hyperthyroidism in post-iodization era based on a hospital based study. Materials and Methods: A total of 516

subjects visiting department of Medicine, Princess ESRA Hospital, Hyderabad, in age group of 10 to 75 years

were included in the study from June 2013 to January 2014. Serum TSH, T3, and T4 assays were assessed by

chemiluminescence method. Based on thyroid dysfunction test results, subjects were classified into

Hypothyroidism, Subclinical Hypothyroidism and Hyperthyroidism. Results: The prevalence of hypothyroidism

was highest in the females 33.52 % (n=173) as compared to males 2.32% (n=12) and hyperthyroidism in females

4.06% (n=21) and 0.19% (n=1) in males. Subclinical hypothyroidism in females was 7.55% (n=39). Conclusions:

An inordinately high increase in the prevalence rate in women was observed particularly in the age group 21-

30years. Monitoring of thyroid profile is necessary to prevent adverse outcome at clinical and subclinical levels

related to infertility, pregnancies and other complications.

Keywords: Hypothyroidism, Hyperthyroidism, Subclinical hypothyroidism, T3 (Triiodothyronine), T4

(Thyroxin), TSH (Thyroid stimulating hormone)

INTRODUCTION

Thyroid dysfunction (TD) has been considered as

one of the most common endocrine disorder in

clinical practice throughout the world.[1]

Its

increasing prevalence had led to the screening of

general population in different parts of the world inorder to investigate causes for rising incidence. The

world wide prevalence of hypothyroidism is

estimated to be around 5%[2, 3]

and that of

subclinical hypothyroidism worldwide is 4-15%.[3, 4]

In this scenario there is a need for further

epidemiological studies in view of high prevalence

reported by some initial studies both hospitals basedas well as population surveys. Some recent reports

from Europe have claimed that the non-toxic goiter

DOI: 10 5958/2319 5886 2015 00095 8


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in the post-iodization era appears to be of auto-

immune type i.e. hypothyroidism. The important

signs and symptoms of hypothyroidism are fatigue,

weight gain, constipation and cold intolerance

whereas anxiety, palpitation, weight loss, increased

appetite and sweating are important signs of

hyperthyroidism. In a study by Doufas et al (1999)[5]

it has been reported that apart from genetic and other

environmental factors iodine excess in post-

iodization era is considered to play an important role

in the rising incidence of hypothyroidism of

autoimmune type. Due to less awareness as well as

less attention towards diagnostics of hypo and hyper

thyroidism in India a considerable percentage of

population, particularly women suffer from thyroid

dysfunction which is considered as a common organ

specific autoimmune disorder.[1]

A nation-wide study by Unnikrishnan et al. (2013)[ 6]

on epidemiology of thyroid dysfunction in selected

cities of India suggested the need for further studies in

order to have a more comprehensive analysis of

epidemiological aspects for better awareness and

control of this endocrine disorder. Important factors

that have been considered in such studies are age at

onset, and gender ratio, and the relative prevalence

rates of hypothyroidism and hyperthyroidism. In the

present study emphasis has also been laid on the

prevalence of subclinical hypothyroidism which may

have various consequences such as increasing risk of

cardiovascular disease, hyperlipidemia, somatic and

neuromuscular symptoms, reproductive and other

consequences as thyroid stimulating hormone (TSH)

levels above the normal range can cause such ailments.

In 1983 when India adopted the universal salt

iodization programme it is noted that in post iodization

period there was decline in goiter prevalence in several

parts of the country. But the prevalence is estimatedabout that still 42 million people suffering from

thyroid dysfunction.[7]

There is a need for further

studies on the prevalence of thyroid disorder in post

iodization period in order to investigate the new

emerging trends in the prevalence of TD.

MATERIALS AND METHODS

The study was conducted after taking approval from

Institutional Review Board, Deccan college of Medical

Sciences, Hyderabad.This was a unicentric, prospective based study. A

total of 516 subjects visiting Department of

Medicine, Princess ESRA Hospital, Hyderabad for

general health checkup in the age group of 10 to 75

years (those male cases who reported for thyroid

profile checkup were also included) were screened

after taking informed consent from them. Each

subject was given a reference number for further

reference. Only cases with primary thyroid disorders

were considered to be included under inclusion

criteria whereas cases suffering with secondary and

tertiary hypothyroidism and chronic illness were

excluded from the study.

Methodology: All the subjects underwent the

assessment of physical examination, medical history

and laboratory investigations. From each patient

aseptically 2ml of blood was collected and serum

was separated. The serum was used for the following

thyroid profile biochemical analysis within 24 hours

from collection. Serum TSH (Thyroid stimulating

hormone), T3 (Triiodothyronine), and T4 (Thyroxin)

assays were done by chemiluminescence method

(Helfand et al)[8]

(Biomerieux, France, 3rd

Generation). Based on TD test results, subjects were

classified as shown in Table 1. Statistical analysis:

Statistical analysis was performed for all the subjects

enrolled in the study as per the protocol. All

statistical analysis was performed using Graph Pad

Prism software Version 5.0 (San Diego, CA, USA).

The prevalence of hypo, hyper and subclinical

hypothyroid was expressed as counts and

percentage. Distribution of various parameters such

as age and gender among hypo, hyper and

subclinical hypothyroidism was calculated using

Fisher’s exact test. P value ≤0.05 was considered

statistically significant for the all variables.

RESULTS

A total of five hundred and sixteen (516) subjects

were included in the study from June 2013 to

January 2014. Out of these four hundred and eighty

seven (487) subjects were females and the remaining

29 subjects were males falling in the age range of 10

to 75. However, the percentages of cases suffering

from hypothyroidism were 185(35.85%), sub

clinical hypothyroidism 39(7.55%), and

hyperthyroidism 22(4.26%) (Table 2 and Fig. 1).

The number of hypothyroid cases were significantly

higher than hyperthyroid as well as subclinicalhypothyroid cases ( p


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Subjects who were already diagnosed as suffering

from thyroid dysfunction and were on Levothyroxin/

Eltroxin/ Carbimazole etc constituted a total of

31.25% (n=145) with hypothyroidism and 1.93%

(n=9) with hyperthyroidism (Table 3). The number of

newly diagnosed hypo cases was 39 (7.55%) and that

of hyperthyroid cases 13 (2.52%). The total number of

already diagnosed hypothyroid cases were

significantly higher than that of newly diagnosed

hypothyroid cases ( p


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Fathima et al.,

*Number of cases in the age gro

significantly higher than other age

with hypothyroidism ( p


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hypothyroid and responded to the treatment with

levothyroxin.[14]

Various endogenous factors are attributed to higher

predisposition of females particularly in younger age;

these include hormonal imbalance at puberty,

pregnancy, higher level of estrogen which cause rise in

TSH levels which in turn induces expression of major

histo compatibility (MHC) class II molecules on cells

including thyrocytes which may present self antigens

released due to infection of the thyroid there by setting

in motion the process of auto-immunity.[12]

The skewed X-chromosome inactivation (XCI)

hypothesis for high susceptibility to hypo is also

gaining more credence as it claims that the existence

of XCI in females results in self antigen express ion in

the thymus or in other peripheral sites which is

involved in tolerance induction. Because of this

reaction skewed XCI has been identified as a

predisposition factor for the development of AITD.[15,

16]

Multiple genes are implicated in the causation of

thyroid disorders which are mainly grouped into those

that are responsible for coding thyroglobulin, TSH

receptors etc and the other group comprises of those

genes that are responsible for immunoregulatory

molecules and cytokines. Single nucleotide

polymorphisms in some of these have been reported to

be associated with increased risk of thyroid

dysfunction.[17]

In the present study the protocol did not include

specific reasons for getting the thyroid profile tested.

However it appears that a systematic analysis of

thyroid profiles of patients visiting hospital appears to

be of significant importance in identifying emerging

trends in the prevalence of hypothyroidism.

These reports appear to represent emerging trends of

high prevalence of both overt and subclinical hypo inwomen. These studies lend support to the results of

high prevalence of hypothyroidism reported in this

study, and indicate that the TSH levels are very crucial

as they may have serious consequences, they may also

affect cardiovascular and neuromuscular

manifestations.[18]

It is suggested that iodine intake of a population

should be kept within a relatively narrow range

interval that prevents iodine disorders, but not higher.[12]

Limitations of our study are that it was performed

on a modest sample size. Secondly no test was

performed for screening for anti-TPO or antibodies.

Finally, with regard to the significant cause of TD

etiological factors may be one of the better

explanations along with iodine sufficient status. It

is suggested that further studies on similar lines

may be carried out both at the population base as

well as in the hospital with relatively larger sample

size in order to draw more definitive conclusion.

CONCLUSION

This appears to be an increasing trend in the

prevalence of thyroid disorders particularly

hypothyroidism in the post-iodization era in India.

An inordinately high increase in the prevalence rate

in women is observed particularly in the age group

21-30years (Fig. 2) and indicating the need toexplore possible molecular mechanisms underlying

this trend. Monitoring thyroid profile and adopt to

suitable measures to prevent adverse outcome as

clinical, subclinical levels have been related to

infertility, pregnancies and also cardiac problems

particularly heart failure.

ACKNOWLEDGEMENTS: None

Conflict of Interest: Nil

REFERENCES

1. Karla S, Unnikrishnan AG, Sahay R. The global

burden of thyroid disease. Thyroid Res Pract.

2013;10: 89-90.

2. Hollowel JG, Staeching NW, Flanders WD,

Hannon WH, Gunter EW, Spencer CA, et al.

Serum TSH, T(4), and thyroid antibodies in the

United States population (1988 to 1994).

National Health and Nutrition Examination

survey (NHANESIII). J Clin endocrinol

Metabol. 2002;87: 489-99.

3. Hoogendoom EH, Hermus AR, De vegt F, Ross

HA, Verbeek AL, Kiemency LA, et al. Thyroid

function and prevalence of anti- thyroperoxidase

antibodies in a population with borderline

sufficient iodine intake: Influence of age and

sex. Clin chem. 2006;52: 104-11.

4. Bemben DA, Hamm RM, Morgan L, Winn P,

Davis A, Barton E. Thyroid disease in the

elderly. Part 2. Predictability of subclinical

hypothyroidism. J Fam pract. 1994;38: 583-88.


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5. Doufas AG. The predominant form of non-toxic

goitre in Greece is now autoimmune thyroiditis.

Eur J Endocrinol.1999; 140: (6):505.

6. Unnikrishnan AG, Karla S, Sahay RK, Bantwal G,

Jhon M, Tewari N. prevalence of hypothyroidism

in adults: An epidemiological study in eight citiesof India. Ind J Endocr Metab. 2013; 17: 647-52.

7. Abraham R, Murugan VS, Pukazhvanthen P, Sen

SK. Thyroid Disorders in Women of Puducherry.

Ind J Clin Biochem. 2009;24: 52-59.

8. Helfand M, Crapo LM. Screening for thyroid

disease. Annala for thyroid disease. Annals Intern

Med. 1990; 112(11): 840-49.

9. Chauhan VK, Manchanda RK, Narang A,

Marwaha RK, Arora S, Nagpal L, et al. Prevalence

of thyroid disorders in school children in Delhi-

Post Iodization Scenario. Ind J Res Homoe.

2009;3(3):50

10. Shekhar R, Prabodh VS, Chowdary NVS, Vidya

D, Das MC. Prevalence of thyroid disorders in

coastal Andhra Pradesh. Int J Pharma Bio Sci.

2012;3(3): 596-03.

11. Canaries GJ, Manowitz NR, Mayor G, Ridgway

EC. The Colorado thyroid disease prevalence

study. Arch Int Med. 2000; 160: 526-34.

12. Aghini-Lombardi F, Antonangeli L, Martoni E,

Vitti P, Maccherini D, Leoli F, Rago T, Grasso L,

Valeriano R, Balestrieri A, Pinchera A, et al. The

spectrum of Thyroid Disorders in an Iodine-

Deficient Community: the Pescopagano Survey. J

Clin Endocrinol Metab. 1999;84: 561-66.

13. Sarnac L, Zivanovic S, Bjelakovic B, Stamenkovic

H, Novak M, Kamenov B. Why is the thyroid so

prone to autoimmune Disease? Horm Res

Paediatr. 2011;75(3): 157-65.

14. Verma I, Sood R, Juneja S, Kaur S. Prevalence of

hypothyroidism in infertile women and evaluationof response of treatment for hypothyroidism on

infertility. Int J Appl Basic Med Res. 2012;2(1):

17 – 19.

15. Laufer TM, Dekoning J, Markowitz JS, Lo D,

Glimcher LH. Unopposed positive selection and

autoreactivity in mice expressing class II MHC

only on thymic cortex, Nat. 1996; 383:81-85.

16. Kyewski B, Derbinsli J. Self- representation in the

thymus: anextended view. Nat Rev Immunol.

2004;4: 688-98.

17. Tomar Y, Huber A. The etiology of autoimmune

thyroid disease: a story of genes nd

environment. J Autoim. 2009;32(3-4): 231-39.

18. Kostoglou AI, Ntalles K. Hypothyroidism-new

aspects of an old disease. Hippok. 2010; 14(2):

82-87.

‘


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&

Health Scienceswww.ijmrhs.com Volume 4 Issue3 Coden: IJMRHS Copyright @2015 ISSN: 2319-5886

Received: 3rd Feb 2015 Revised: 28th Feb 2015 Accepted: 16th Mar 2015

Research article

UNMET NEED OF SEX EDUCATION AMONG ADOLESCENTS IN URBAN SLUM AREA: AN

INTERVENTIONAL STUDY

*Tamboli Kshitij S1, Avachat Subhada S

2, Tamboli Suchit S

3

1Medical Intern, PDVVPF’s Medical College, Ahmednagar, Maharashtra, India

2Associate professor, Department of Ccommunity Medicine, PDVVPF’s Medical College, Ahmednagar,

Maharashtra, India3

Consultant, Chiranjiv clinic and child development centre, Ahmednagar, Maharashtra, India

* Corresponding author email: [email protected]

ABSTRACT

Context: Adolescents comprise one-fifth of India’s total population. There is widespread ignorance associated

with unprotected sex, contraceptives, among young people. As majority adolescents in slum areas have illiterate

and ignorant family backgrounds; they are misguided by the myths. Hence providing sex education for them is the

need of the hour. Aims: 1) To assess the knowledge and awareness of adolescents in an urban slum area

regarding some aspects of reproductive health. 2) To assess the need of sex education among them. 3) To study

the impact of sex education on their knowledge Material and Methods: An interventional study was done on

132 adolescents of urban slum area, selected by simple random sampling. Informed consent was obtained from

the participants. Data was collected with the help of structured questionnaire prepared by literature search.

Response of adolescents was recorded through questionnaires. A sensitization workshop was organized as

intervention. The same questionnaire was given to them and the effect of intervention was assessed. Statistical

analysis of data was done using percentage, proportion and appropriate tests of significance. Result and

Conclusions: Only 31.06% adolescents had discussed the topic of reproductive health with some or other person

and out of them friends were the major sources (39.2%) of information. Only 38.63% knew the hazards of teenage

pregnancy which significantly rose to 89.4% after intervention workshop. The study concludes that the slum

adolescents profoundly lack adequate knowledge of sexuality related matters. Even before intervention workshop,

unmet need of reproductive health education was 59.1% and 93.93% was the felt need in the post test.

Keywords: Adolescent health, Sex education, Urban slum area, Intervention

INTRODUCTION

The period between 10-19 years is referred to as

"adolescence" by the World Health Organization

(WHO). There are 225 million adolescents

comprising nearly one-fifth (22 %) of India’s total

population. Of the total adolescent population, nearly

10% are in the 15-19 years age group.

Adolescent sexuality is still a taboo in many societies;there is widespread ignorance about the risks

associated with unprotected sex, contraceptives etc.

among the young people[1]

. Teenagers are still

hungry for accurate, adequate information about sex

and sexuality and yearn to hear about it openly and

honestly[2]

. There seems increase in the prevalence of

adolescent sexual problems due to lack of knowledge

in them. It is now thought that around 2.39 million

people in India are living with HIV. Highest HIVprevalence among the age group 15-19 is 0.04%. It is

0.01%in males, 0.07% in females, according to

DOI: 10 5958/2319 5886 2015 00096 X


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NFHS-3 2005-06, India: Volume- 1. Teenage

pregnancy is one of the main problems in the world,

its prevalence rate varies from 2 to 25%[3]

.

Sex education includes information regarding human

sexual behaviour, sexually transmitted diseases

(STDs), HIV/AIDS and other aspects of human

sexuality such as body image[4]

. Adolescence is a

fascinating period of life that makes the transition

from being a dependent child to becoming an

independently functioning adult[5]

. Providing

adolescents with proper sex education will minimize

their risks and hence the prevalence of sexually

transmitted diseases and will in turn help to control

the problems of HIV/AIDS, teenage pregnancy.

As majority adolescents in slum areas have illiterate,

ignorant family backgrounds, they may be misguided

by the information from peers & media. Right

guidance regarding reproductive health may not be

available for such adolescents and they may not

utilize the available health facilities despite having

queries on such a topic.

Educational intervention programs can help in

creating and promoting awareness among the youth

and women. A study by Dongre et al. (2006) showed

significant improvement in personal hygiene of

students and concluded that the school health

education programs with active involvement of

school teacher lead to improvement in personal

hygiene in school children and reduction in related

morbidities[6]

. Twenty-two international studies were

done in various developing countries which showed

sufficiently strong evidence that these interventions

reduces risk behaviour[7]

.

Keeping above background in mind, an intervention

study in adolescents of slum area, including

awareness programs in the form of workshops and

lectures was deliberately planned, by which we couldidentify their thrust areas and give proper emphasis

on them to provide solutions.

MATERIAL AND METHODS

Study design: An intervention type of study.

Study area: Urban slum area in Ahmednagar,

Maharashtra, India.

Study participants: Adolescents in the age group of

15 – 19 years.

Study duration: April 2014 to September 2014.

Inclusion Criteria: 1) Adolescents living in the slum

area, belonging to the age group 15 -19 years. 2)

Subjects ready to participate in the study.

Exclusion Criteria:1) Adolescents who were not

willing to participate in the study. 2) Adolescents

from the age group 10-14 years.

Sampling technique: Simple random sampling

technique was used to select urban slum from

amongst 8 slums and the participants from the study

area. Sample size: 132 adolescents (44 boys and

88girls).

Ethical approval: The study was initiated after the

approval was taken from the institutional ethical

committee of Medical College.

Data collection: Informed consent was obtained from

the participants /parents (for minors) and

confidentiality regarding personal information of the

participant was maintained. Data collection was done

with the help of structured questionnaire prepared by

literature search[3],[8]

. NOTE: A female attendant

accompanied while collecting the data from the girls.

The questionnaire had questions testing the

knowledge of participants regarding puberty,

reproductive health, sexuality, physical and mental

changes and sexually transmitted diseases. Few

questions were open ended and a few close ended..

The questionnaire was translated in the local

language (Marathi). Response of adolescents was

recorded in writing format by giving 1 copy of

questionnaire to each subject. A sensitization

workshop was organized as a part of the intervention,

after collection of data that is after the pre-test. This

workshop was held separately for boys and girls. The

various methods used for health education were

informative pamphlets, lectures, group discussions,

CD’s and posters regarding various aspects of

reproductive health, role plays were taken separatelyfor boys and girls. Need regarding various aspects of

sexuality was identified, thrust areas were noted and

accordingly the solutions were given in the workshop.

Immediately after this, same questionnaire was given

to the participants’ for post test and data was

statistically analyzed to see the effect of intervention

on the subjects.

Statistical analysis of the data: Data was compiled

and put up in an excel sheet. It was then analyzed

using percentage, proportion and appropriate tests of significance were used.


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Kshitij et al.,

RESULTS

Sociodemographic distribution: Ag

data is shown in Fig 1. Out of the t

(88) were males and 33% (44) were

Knowledge of reproductive health:

adolescents out of 132sexuality/reproductive health so

someone earlier in their life. Thos

answer as “yes”, they discussed

friends (39.02%), parents (12.2

counsellor (14.63%), elder brother

Knowledge of adolescents in the

signs of puberty is depicted in tabl

of puberty was known to 10.6% of a

intervention while it improved to

intervention. 39.4% of adolescentsregarding “Legal age of marriage

improved significantly to 92.

intervention. Only 17.42% of adol

safe minimum age of the pregnancy,

significantly to 74.24% after the inte

Knowledge regarding contraceptio

about the places where contracepti

before intervention which increase

the intervention. Only 3 (2.72%) a

the total sample were able to enlivarious contraceptives in the pretest

test, 31 (23.48%) of the adolescents

correctly. 70.5% of males thoug

condom can be used more th

intervention while after interventio

answered that, a same condom cann

Knowledge regarding hazards of te

is shown in table 2. Knowledg

regarding hazards of unsafe sex is

3. In post test67% of adolescents

all 4 modes of transmission of

20.5% boys had information regard

before intervention while 79.54%

post intervention. Only (48.86%) f

someone (any source) earlier disc

about menses before menarche w

wrote that nobody had discussed wit

menses earlier. Those who had disc

wrote mother (81%) as a source m

siblings (7%) and friends (7%)

Type of material used during me

depicted in Fig 2.

Int J Med Res Health Sc

e distribution of

tal (n=132), 67%

females.

nly 41 (31.06%)

had discussed me time with

e who wrote the

the subject with

), doctor/health

sister (19.51%).

study regarding

1. Age of onset

dolescents before

77.27% after the

had knowledge in India” which

2% after the

scents knew the

, which improved

rvention.

n: 40.15% knew

on was available

to 93.18% after

dolescents out of

ist the names of while in the post

were able to do it

ht that a same

an once before

n 96% of males

t be used twice.

enage pregnancy

of adolescents

isplayed in table

ere able to write

IV/AIDS. Only

ing masturbation

had knowledge

males wrote that

ussed with them

hile 45(51.14%)

h them regarding

ussed the subject

stly followed by

nd others (5%).

nses by girls is

Table 1: Knowledge o

regarding signs of pube

Pre test

Correct 01(0.75%)

Incorrect 131(99.2%)

Total 132

p


23/263

Kshitij et al.,

Unmet need of reproductive educat

in prevention: Response of adolesce

reproductive education is ment

4.Providing reproductive health edu

preventing Sexually transmitted dis

pregnancy, Physical & psychologi

puberty was the response of 130 (9

adolescents in the study. The pre

Information for reproductive educat

teachers (48%), health workers an

parents and siblings (7%), media

and other sources (3%).

DISCUSSION

In our study, most of the adolescentaccess to information regarding

Majority of them wrote ‘friends

‘siblings’ (19.51%) as prominent

which they got to know inform

subject. In a similar intervention st

sector, 217 adolescents were invol

‘friends’ as source of information[9]

done in the slums of Mumbai, 5.66

had no access to information regardi[10]

.

In our study,67% of the adolesce

enlist all the modes of transmissi

after the intervention. The NACO r

30% of the boys (15-19 years old) k

virus is transmitted, with slight v

urban and rural boys. An ICMR

about one-half of the adolescents

condoms and were confused about t

of HIV/AIDS transmission.

In our study, only 0.75% of adolesc

answers about signs of puberty in

before intervention which signi

Int J Med Res Health Sc

ion and its value

ts to necessity of

ioned in table

ation will help in

eases, Unwanted

cal problems in

.5%) of the total

erred sources of

ion were: school

doctors (36%),

(6%), magazines

s 69.94% had no sex education.

’ (39.02%) and

sources through

ation about this

dy done in rural

ved,69.58% gave

n a similar study

of the students

ing sex education

nts were able to

n of HIV/AIDS

ported that about

ow how the HIV

riations between

study stated that

ere not aware of

he various modes

ents gave correct

ales and females

icantly rose to

47.73%.This indicates

regarding puberty. It sho

marriage which is a bas

known to many adolesce

Study by Singh.D[11]

,

adolescents profoundly l

knowledge of sexuality

could correctly answer

percent of slum adolesc

genital development a

pubertal changes among

knowledge of these chan

body.

In our study,38.63% of t

knew the hazards of te

study which significa

intervention. Thus, emp

of girls would be a suc

marriage of girls an

adolescent pregnancy[12]

.

Our study shows that f

knowledge regarding var

health but they were rel

males. 48.86% of fem

about menses with so

menses. Prominent sour

them. An ICMR study c

not been informed about

changes prior to its onset.

In our study, the un

education is clearly note

59% adolescents agreed

the knowledge. 94% adol

education during and

sources of information

school teachers (48%),he

a study by Singh D, theslum adolescents nee

regarding 'how and what

when an individual pass

Similarly, poor baseline

knowledge after interve

other studies[13,14]

. In a

et al , the intervention

child health showed a

knowledge levels of girl

7.924 at 1 percent levelbyPadhyegurjar Mansi et

school curriculum was

499

i. 2015;4(3):496-501

clear lack of knowledge

ld be noted that legal age of

ic important aspect was not

nts before intervention. In a

it is noted that the slum

ck appropriate and adequate

related matters. 3.7% only

about puberty. Merely 12

nts knew that Nightfall and

re the initial features of

males and 88 per cent had no

ges that taken place in their

e adolescents only correctly

nage pregnancy in present

tly rose to 89.4% after

asizing on health education

essful strategy for delaying

consequently preventing

males also lacked adequate

ious aspects of reproductive

atively more informed than

ales had already discussed

e source before onset of

ce was mother for 81% of

oncluded that most girls had

menarche and other pubertal

.

met need of reproductive

as even before intervention

to the necessity of obtaining

lescents felt the need of such

fter intervention. Preferred

as noted in the study are

alth worker/doctor (36%). In

findings suggest that these an intensive education

physical changes' take place

through adolescent period.

knowledge and increase in

ntion has been observed in

study by Shubhagna Sharma

regarding reproductive and

significant effect in the

s as seen by t-test value of

f significance

[15]

.In a study .al , need of sex education in

erceived by 94.72 % of the


24/263

500


students even before intervention. After the sessions

on sex education, this increased significantly to 97.36

% and preferred sources of knowledge of sex

education , a large majority of 83.02 % students

preferred doctors to impart sex education, followed

by teachers (40%) and television (30.19%).

CONCLUSIONS

The present study was done in the urban slum area.

The prominent sources of information were friends

for most of the adolescents. The study concludes that

the slum adolescents profoundly lack appropriate and

adequate knowledge of sexuality or sexuality related

matters. Regarding pubertal changes, the girls had

better knowledge as compared to boys. Knowledge of

adolescents regarding puberty and regarding of thehazards of teenage pregnancy rose significantly after

intervention program. Before intervention workshop,

unmet need of reproductive health education was

noted among adolescents and felt need increased in

the post test. Most of the adolescents want school

teachers as the source of reproductive health

education.

Advantages of this study were: we could bring forth

the unmet need of sex education in urban slums areas

that we selected. We could give them intervention

workshop which would help them in their past and

future unanswered questions regarding this topic.

Limitations: Due to time constraint we could not

include all the subtopics about sexual health while

providing intervention program.

Recommendations borne out of this study: Timely

assessment of adolescents’ health and development

needs by similar type of studies will help to find

aspects like unmet need of reproductive health

education in this age group. Sex educationincorporated in the school/college curriculum is the

need of the hour that can help to fill up the gaps by

updating their knowledge. Involvement of parents in

reproductive education: Educating the parents and

conducting education programs to increase awareness

of reproductive health can be another important task

which will help in turn in giving proper information

to adolescents. Involvement of NGOs to a much

greater extent: Informational and educational

activities through NGOs can be accelerated toenhance knowledge of adolescents. PHC’s can take

lead role to cover this neglected aspect by properly

utilizing medical and paramedical workers and

strengthening of the public health care system at all

levels, to deliver RCH services. Thus, empowering

adolescents to take care of their own health as well as

protect themselves from possible health problems like

unwanted pregnancies, risk of STDs in their future

life will be important and should be done by

implementing the recommendations.

ACKNOWLEDGMENTS

We are grateful to Mrs. Neha Tamboli, counselor for

conducting workshop amongst girls, “Snehalaya”

Ahmednagar and Mr. Hanif for their cooperation in

conducting workshop. We are grateful to Dr.Mrs

Zambre for guidance and Miss Shradha for technical

support.

This research paper was presented as oral

presentation at “11th

WARSAW INTERNATIONAL

MEDICAL CONGRESS” held at Poland in May,

2015, and has received best presentation award.

REFERENCES

1. Park K, Park’s Textbook of Preventive and Social

Medicine. Jabalpur: Bhanot Publishers;2009;20th

edition:511- 2.

2. Nair MKC, Sexual reproductive health of youngpeople. Jaypee Publishers: 2006; First edition: 27.

3. Bhave S, Bhave’s textbook of adolescent

medicine. Jaypee publishers:2006;first

edition:178-184.

4. Bhatlavande P, Gangakhedkar R — On the

Horizon of Adulthood.New Delhi: UNICEF;

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5. Nair MKC, Bodhankar U. Adolescent health

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6. Dongre AR, Deshmukh PR, Garg BS. The Impact

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Personal Hygience and Related Morbidities in

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7. Kirby D,Obasi A. The effectiveness of sex

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9. Avchat S, Phalke D , Phalke V .Impact of sex

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2011 :33-35.

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Assessment of felt needs and effect of health

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http://njcmindia.org/uploads/3-2_221-226.pdf

11. Singh.D- Knowledge of slum adolescents about

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Health and Population- Perspectives and Issues

2000;23 (4): 198-204.

12. Thekkekkara T, Veenu J - Factors Associated

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14. Russel-Brown P, Rice JC, Hector O. The

effect of sex education on teenagers in St. Kitts

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Chopra- Health Awareness of Rural Adolescent

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Thomas et al., Int J Med Res Health Sci. 2015;4(3):502-505


&

Health Scienceswww.ijmrhs.com Volume 4 Issue 3 Coden: IJMRHS Copyright@2015 ISSN: 2319-5886

Received: 18th Feb 2015 Revised: 20th Mar 2015 Accepted: 28th Apr 2015

Research article

HOW DO MEDICAL STUDENTS LEARN? A STUDY FROM TWO MEDICAL COLLEGES IN SOUTH

INDIA – A CROSS SECTIONAL STUDY

*Christofer Thomas1, Praveen K Kodumuri

2, Saranya P

3

1Department of Physiology, Sapthagiri Institute of Medical Science and Research Center, Bangalore, Karnataka

2,3Department of Physiology, Mamata Medical College, Khammam, Telangana

* Corresponding author email: [email protected]

ABSTRACT

Introduction: "Learning style" is defined as an individual's preferred method for approaching learning and

gaining knowledge. As a teacher, it is important to understand the different learning styles of the students in

acquiring the information, and hence one can make the necessary changes that best match the learning style of the

students. Assessment of learning styles can be done in various ways but Visual Auditory Reading Kinesthetic

(VARK) questionnaire is the most accepted one among them. The present study was undertaken to determine the

learning preferences of first year medical students in South India. The study was also aimed at determining

whether males and females have simila

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