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CONTENTS Page No.

DIABETIC RETINOPATHY: HYPERGLYCEMIA MEDIATEDBIOCHEMICAL DERANGEMENTS, THE KEY INITIATORFOR THE PROGRESSION OF THE DISEASE PATHOLOGY

… … … Suman K. Paine, Lakshmi K. Mandal, Tandra Ghosh, Subhadip Choudhuri … 3

FEASIBILITY OF APPLICATION OF E-LEARNING IN INDIANFIRST YEAR MEDICAL STUDENTS: STUDY TO ASSESSINFRASTRUCTURE, SKILLS AND ATTITUDE

… … … Dnyanesh B. Amle, Swati Hiwale, Gajendra Kumar Singh, P K Patra … 11

CORRELATION OF FASTING PLASMA INSULIN ANDC-PEPTIDE LEVELS IN PATIENTS WITH TYPE 2 DIABETES MELLITUS… … … Maninder Kaur,Maninder Sandhu, Gurdeep Kaur Bedi,Raminderpal Singh Sibia … 20

ADOPTING ROLE PLAY FOR TRAINING MEDICAL INTERNS ABOUTSAMPLE COLLECTION AND PROCESSING FOR LABORATORY INVESTIGATIONS

… … … Mohit Mehndiratta, Dinesh Puri .... 24

STUDY OF SERUM VITAMIN D AND PARATHYROID HORMONELEVELS IN CHRONIC KIDNEY DISEASE PATIENTS

… … … Anita, Seema Patel, Karthik T, Vindu Amitabh, B.C Kabi … 28

HIGH SENSITIVITY C-REACTIVE PROTEIN - A CARDIAC MARKERFOR THE SCREENING OF DIABETES MELLITUS PATIENTS

… … … Sankar Roy, Avik Chakraborty, N. Gan Chaudhuri, Shib Shekhar Datta … 34

ROLEPLAY: A METHOD OF TEACHING BIOCHEMISTRY TOMEDICAL UNDERGRADUATES

… … … Mohit Mehndiratta, Stuti Gupta, Dinesh Puri … 39

A PERSPECTIVE ON MAGNESIUM IN DIABETIC RETINOPATHY… … … P. Gupta, R. K. Goswami … 42

Editorial

Deciphering Painful Diabetic Neuropathy

Neuropathy is a common and costly complication of both type 1and type 2 diabetes mellitus. The prevalence of neuropathy isestimated to be about 8% in newly diagnosed patients and

greater than 50% in patients with longstanding disease. Patients withdiabetic neuropathy are at an increased risk for developing ulcers,recurrent foot infections, and Charcot joints, bony destruction anddeformation due to repetitive traumatic injury, often associated withreduced sensation in the feet. Consequently, diabetic neuropathy is thecause of 50-75% of non-traumatic amputations. Diabetic neuropathyhas a profound impact on patients’ quality of life and is responsible formajority of diabetes-associated morbidity and mortality.

Regarding, patho-physiological causes of diabetic neuropathy,microangiopathy in the peripheral nerve blood vessel, triggered byoxidative stress, accumulated advanced glycated end product(AGE),altered protein and lipid oxidized products are key mediators ininducing nerve damage in diabetes in humans and experimentalmodels. Among the other causes neuron damage by altered polyols isanother important reason. Similarly, poor glycemic control also hasbeen recognized as another important risk factor for the developmentand progression of neurological complications.

The understanding of the damage of type of nerve is also important.Unmyelinated and thinly myelinated sensory neurons are moredamaged than autonomic and long motor neurons, leading to alteredtemperature and pain perception earlier, than abnormal vibration andtouch perception. Autonomic function is found to be altered in 70-80%cases of sensory-polyneuropathy, leading to increased heart rate,postural hypotension, diabetic gastroparesis etc. The major hurdle isto objectify the extent of neuron damage, as quantitative sensory testingto identify the damage of sensory neurons is mainly subjective. On theother hand, it is clearly established in animal studies that early damageof sensory neurons is reversible. Unlike other microangiopathiccomplications like retinopathy and nephropathy, where we havesensitive markers for early detection, which makes early interventionfeasible; no such reliable sensitive tool exists for detection of diabeticneuropathy till date. This is the main reason behind failure ofprevention and treatment of diabetic neuropathy. Currently diagnosisof diabetic neuropathy is mainly symptom based. Sensory symptoms

vary from pain hypersensitivity to loss of symptoms. Several positivesymptoms like burning pain, tingling is more common than negativesymptoms like numbness and dysesthesia. Altered sensation leads todecreased quality of life in patients, altered sleep, predisposition todiabetic foot ulcer disease.

So the current hurdle in prevention of diabetic neuropathy is mainlytwo. First to identify the onset of neuropathy at an early stage andsecond, identification of the specific molecule related to altered sensorysymptoms in peripheral nervous system. Among, the several Researchgroups, German Research Network are trying to objectify quantitativesensory testing more precisely, developing more sophisticated tools likecorneal confocal microscopy and measuring small fibre action potentialby using laser, on the other hand studies are going on to identify themore specific molecules in peripheral nerve damage. But there is a wayto go to make the application in routine clinical practice and bedsidetesting.

The drugs presently available for management of diabetic neuropathyare mainly nonspecific, acting centrally like amitriptilline andpregabalin; most of them are from antiepileptic and antidepressantgroup. For specific intervention, research is going on pathomechanismof different pain phenotype (positive, negative, dysesthesia). Oneexample is like transient receptor potential ankyrin 1(TRPA1) ionchannel which is expressed on pain mediating peripheral nerve fibresand now is considered a key mediator of pain. Mechanism based andtarget specific research will enable not only to decipher painful diabeticneuropathy but in other types of neuropathic pain related disease likeneurotic leprosy, complex regional pain syndrome, fibromyalgia andwill help to improve the quality of life of these patients.

2 Ind. J. Med. Biochem. Vol. 19, No. 1, 2015

IntroductionDiabetic retinopathy (DR), one of thedevastating microvascular complications ofdiabetes mellitus, the development of whichcorrelates with duration as well as the severity ofhyperglycemia(1,2). The earliest microvasculardysfunction in retina of patients with diabetes isevoked by hypoxia because of autoregulatoryfailure, capillary closure and nonperfusion(3). Ithas been postulated that this hypoxic andischemic retina adjacent to acellular capillaries inturn releases vasoconstrictive agents and growthfactors, which in turn increases blood flow inretina(4,5). Though it has not been clearlyestablished whether hypoxia and its sequel candevelop even without vascular occlusion, in alllikelihood, hyperglycemia may induce theearliest metabolic disparity in the retinalmicrovasculature(6). This is apparent as a changein redox state of retinal microvascular cell, andmanifest biochemically by altered ratio ofpyridine coenzymes and reduced glutathionelebel(7,8). Among the different biochemicalpathways implicated in the pathogenesis of DR,

the process of formation and accumulation ofadvanced glycation end products (AGEs) andtheir mode of actions have been considered asmajor initiator of retinal microvascularcomplications in type 2 diabetes mellitus(41,42).AGEs are nonenzymatically glycated andoxidized proteins or lipids, which accumulate inthe vessel wall, where they may perturb vascularendothelial and pericyte cell structure andfunction. In particular Nε–CML, the mostprevalent AGEs, interact with receptor of AGE(RAGE), which in turn activates signaltransduction pathways that lead to expression ofpro inflammatory genes. AGEs may also modifythe action of free radicals and may thus impacton the function of intracellular protein via theinteraction with RAGE(43-46).The DCCT and UKPDS trials havedemonstrated that strict glycemic control havereduced the risk of diabetic retinopathycompared to conventional therapy in both type1 and type 2 diabetes mellitus(64). However, notall cases of diabetes mellitus in a country likeIndia, can keep strict control of hyperglycemia

DIABETIC RETINOPATHY : HYPERGLYCEMIA MEDIATEDBIOCHEMICAL DERANGEMENTS, THE KEY INITIATOR FOR THE

PROGRESSION OF THE DISEASE PATHOLOGY

Suman K. Paine1, Lakshmi K. Mandal2, Tandra Ghosh3, Subhadip Choudhuri3,4

1Regional Medical Research centre, NER, ICMR2Regional Institute of Ophthalmology, 88, College Street, Kolkata 700073, India

3Department of Biochemistry, Dr. B C Roy Post Graduate Institute of Basic MedicalEducation and Research (IPGME&R), 244B, A.J.C Bose Road, Kolkata 700020, India.

4GD Hospital and Diabetes Institute, Lenin Sarani, Kolkata - 700013, India

Grants and funds in support of the study : This work was carried out through the grant from Indian Council of MedicalResearch (ICMR), Govt. of IndiaFinancial Disclosure : Authors have no commercial association.

Review Article

3

for prolonged period. So, not all cases of DR canbe prevented. In about 50% of patients,retinopathy will progress despite laserphotocoagulation, which is the primary methodof treatment of DR causing vision loss(65). Despitestandard intervention, vision loss from DR stilloccurs at a frightening rate. Therefore, manyresearchers have recently directed their effortstowards the better understanding pathogenicmechanism of microvascular changes in DR inorder to develop effective pharmacologicalprevention of development of DR and todevelop new treatment strategies. The threemajor classes of pharmacological agentscurrently being studied are corticosteroids,VEGF antagonist and agents that are involvedin biochemical pathways (polyol path wayactivation, PKC pathway activation, cellularoxidative stress and formation of advancedglycation end products. Common biochemicalpathway derangement and relatedpathophysiology of diabetic retinopathy)66.In all eukaryotes, the cytosolic free nicotinamideadenine dinucleotide (NAD+/NADH) ismodulated by mitochondrial NAD+/NADH andintra or extracellular lactate and pyruvate via theenzyme lactate dehydrogenase. Hence,cytosolic-free NAD+/NADH is a good sensor ofthe redox state of the cytosol and extracellularmilieu(9,10). Cytosolic NAD+ / NADH ratio fuelsvarious cytosolic enzymes that use glycolyticpathway metabolites as their substrates and inturn alter extracellular lactate to pyruvateratio(11,12).Studies in animal models and in vitroexperiments support the hypothesis thathyperglycemia mediated cellular redox changeis associated with increased reduction of glucoseand oxidation of sorbitol coupled to oxidation ofcofactor NADPH to nicotinamide adeninedinucleotide phosphate positive (NADP+) andreduction of cofactor NAD+ to NADH,respectively(13,14). Cellular redox imbalancedevelops because of the faster transfer ofelectron and protons to free oxidized cytosolic

NAD+, than electrons and protons carried bycytosolic NADH, which are used for adenosinetriphosphate synthesis in mitochondria byoxidative phosphorylation(16,17). This cytosolicreductive stress in cell because of altered cellularredox state is a consequence of increasedoxidation of polyol compound coupled toreduction of NAD+ to NADH(18). This cellularredox imbalance in retina initiates a range ofanomalous biochemical pathways, which areassociated with retinal microvasculature relatedcomplications in subjects with type 2 diabetesmellitus(10,19).A normal reducing environment required forcellular integrity is provided by reducedglutathione (GSH), a major free radicalscavenger and a key modulator of intracellularredox state(20,21). Glutathione reductase mediatedregeneration of GSH from its oxidized form, isdependent on cofactor NADPH produced bypentose phosphate pathway and serves as theprincipal intracellular reductant(22,23). It has beenhypothesized that in an uncontrolledhyperglycemic state, NADPH is largelyconsumed by aldose reductase for reduction ofglucose to sorbitol through polyol pathway. So,deprivation of NADPH diminishes regenerationof intracellular GSH and thus exposing the retinato underlie oxidative stress(24,25,26).A dysregulated NAD+: NADH ratio in cytosolgoverns the activity of several enzymaticreactions of intermediary metabolism that havesome role in the pathogenesis of diabeticretinopathy as the enzymes use NADH andNAD+ as their cofactors(27,28). Increased cytosolicNADH favors the reduction of dihydroxyacetonephosphate to glycerol-3-phosphate byenhancing the activity of glycerol-3-phosphatedehydrogenase. This step is involved in onepathway, that is, denovo synthesis ofdiacylglycerol followed by activation of proteinkinase C, implicated in mediating severalmicrovascular dysfunctions in retinal vascularbed(29,30). Increased cytosolic NADH augmentssuperoxide production by donating an electron


to extramitochondrial NADH oxidase and itselfgets oxidized to NAD+. Hence, production ofcytosolic reactive oxygen intermediates areactively associated with oxygen sensingmechanisms in retinal vascular smooth musclecells(31,32). Nyengaard et al. assessed in vitro effects ofhyperglycemia and hypoxia on cellular redoxstate and observed a significant increase incytosolic NADH : NAD+ ratio and lactate :pyruvate ratio under hyperglycemic andhypoxoc state compared to normoglycemic andnormoxic state(32). Trudeau et al found that underhyperglycemic condition, mitochondria of retinalpericytes showed significant fragmentation andmetabolic dysfunction(33). Zhong and Kowlurareported that diabetes associated mitochondrialstructural defect plays an important role in thedevelopment of diabetic retinopathy(34).Hyperglycemic episodes are believed to have aclose association with oxidative and nitrosativestress, which renders retinal microvascular unitand its associated glia susceptible to free radicalinjury(35).Muller cells are principal glia of retina, positionedcritically between the microvasculature andneurons of retina.Muller cells express high affinityL glutamate/ L aspartate transporter (GLAST),which plays an important role in transport ofextracellular glutamate from synaptic spaces ofretina. Glutamate acts as a neurotransmitter atmore than 90% of the synapses in retina(37).Redox sensing elements present in the GLASTof muller cells regulate the activity of transporterthrough thiol disulfide interconversion.Considerable reduction in activity of muller cellGLAST on exposure to oxidizing agents and itssubsequent reversal by a chemical reductant hasbeen reported(38). Calcium permeable N– methylD – aspartate (NMDA) receptor is an ionotrophicreceptors for glutamate, have been associatedwith glutamate neurotoxicity and calcium influxinto neuronal cells. Influx of calcium in neuronalcells causes release of caspases frommitochondria, which are the key signaling

molecules of apoptosis. So, NMDA receptoroveractivity during hyperglycemic state isbelieved to play an important role inneurodegenerative changes of retina(39,40).AGE bound RAGE worsens microvasculardysfunction through micro vascular endothelialcell permeability and increased production ofreactive oxygen species (ROS) through theactivation of reduced nicotinamide adeninedinucleotide phosphate (NADPH) oxidase(47).Increased production and consequent ineffectiveelimination of ROS by poor cellular antioxidantsystem is one of the major causes for thedevelopment of oxidative stress among patientswith type 2 diabetes mellitus(48). A family of multisubunit (intracellular and membrane bound)NADPH oxidase appears to be the predominantcontributor for endothelial and pericyte ROSproduction, which have been increasinglyappreciated to have a detrimental role in retinalmicrovascular pathophysiology(49,50).Under normal physiological state, defenseagainst reactive prooxidants is provided by asystem of enzymes [superoxide dismutase(SOD), glutathione reductase (GR), glutathioneperoxidase (GPx) and catalase], which arecapable of neutralizing them and prevent excessfree radical production. Hyperglycemiamediated increased generation of AGE impairthe normal activity of these enzymes by alteringtheir chemical structure and inducingconformational changes(51).Cellular events like vascular endothelial cellproliferation, migration, angiogenesis andincreased permeability of retinalmicrovasculature are potently regulated byVEGF(55,56). VEGF isoforms belong to heparinbinding growth factor family, encoded by asingle VEGF gene on chromosome 6p21.3.VEGF exerts its activity via interactions withthree types of receptors, VEGF receptor1(VEGFR1), VEGF receptor 2 (VEGFR2) andVEGF receptor 3 (VEGFR3)(57,58). NFkβ is adimeric transcription factor, which bind DNA atkappa beta binding motif and induce large

Biochemical Derangements in Diabetic Retinopathy 5

number of gene expression that influencesinflammation, cell proliferation, cellular adhesionand angiogenesis(59,60,61). Perhaps TNF-αmediated NFkβ activation pathway is wellunderstood. Whereas oxidants free radicals, thekey cell signaling molecules are believed to playan important role in NFkβ activation(62,63).

Present knowledge and relevant bibliography Deregulation of cellular downstream molecularevent secondary to hyperglycemic episodes inthe cell leads to endothelial and intramuralpericyte loss, which may be the decisive factorin the pathogenesis of DR(53,54). A cross sectionalstudy was done to evaluate erythrocyte redoxstate and its surrogates in patients with differentstages of diabetic retinopathy and theirassociation with cellular metabolic derangementdeveloped in retinal microvascular cells.Erthrocyte NADP+ / NADPH ratio was found tobe significantly higher among NPDR and PDRpatients compared to diabetics withoutretinopathy (DC). Erythrocyte NAD+/NADHratio was also significantly decreased in patientsof NPDR and PDR compared to DC. Erythrocytereduced glutathione was significantly decreasedin patients of NPDR and PDR. Lactate topyruvate ratio of plasma and vitreous wassignificantly elevated in patients of NPDR andPDR compared to DC. This study highlights thathyperglycemia mediated erythrocyte redox statealterations may the potential risk factor for thedevelopment of NPDR in poorly controlleddiabetes mellitus(67). Further, our second studyhas revealed an association of hyperglycemiamediated increased advanced glycation anderythrocyte antioxidant enzyme activity indifferent stages of diabetic retinopathy showedthat erythrocyte superoxide dismutase andglutathione reductase activity were significantlylower in NPDR and PDR subjects compared todiabetic without retinopathy(68). Our anotherrecent study had showed a pivotal role of N-epsilon carboxy methyl lysine (Nε-CML), inadvanced glycation end products and reactive

oxygen species (ROS) for the development ofnonproliferative and proliferative retinopathy intype 2 diabetes mellitus, which further suggestsNε- CML and ROS are the key modulators forthe development of nonproliferative retinopathyamong poorly controlled type 2 diabetesmellitus(69). A cross sectional longitudinal studyon type 2 diabetic subjects demonstrated thatincreased anaerobic glycolysis to be the centreof biochemical derangement related to apoptosisof retinal micro vascular cells, and laterupregulation of vascular endothelial growthfactor (VEGF) and its receptor (VEGFR2)(52).A cross sectional study reported strongassociation between decreased visual acuity andhigher blood lactate level in type-2 diabetesmellitus. It indicates dysfunction of retinalneurons occurs before manifestation ofmorphological abnormality(71). Anotherpreliminary study on the efficacy of topicaladministration of alpha-2 agonist to reduceischaemia in the very early stage of diabeticretinopathy in good controlled type-2 diabetesmellitus was done. Visual acuity was improvedto one line in 60% patients of brimonidinegroup. Visual acuity was reduced to one line in80% and two lines in 20% patients of the controlgroup. Further any new microaneurysm was notdetected in 100% patients of the brimonidinegroup and 4 new microaneurysms were detectedin(72). Another case –control study was done on“alteration of timing of secretion of vascularendothelial growth factor responsible forprogression of diabetic retinopathy”. This clinicaland biochemical study suggested that early partof diabetic retinopathy may be caused bydecreased oxidative phosphorylation, increasedoxidative stress and increased intracellularaccumulation of Ca2+. Progression of thiscomplication is guided by increased secretion ofVEGF(73).

Conclusion and future scopeBased on previous studies and our observations,it may be hypothesized that chronic uncontrolled


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AcknowledgementThe authors greatly appreciate the fundingagency Indian Council of Medical Research,Govt. of India to carry out this study.



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Introduction Owing to vast medical curriculum, limited hoursavailable for classrooms and a large number ofstudents in the classroom, conventional mode ofteaching which is lecture centered, plays a majorrole in medical teaching. This is because lecturesclearly stand as a feasible way to caterknowledge to the large subset of students withina limited time.(1,2) However lectures do harborcertain disadvantages as an inability to attractactive participation from students and togenerate uniform interest throughout for allstudents. Further success of lecture to effectivelydeliver knowledge depends on academicexpertise and oratory skills of the teacher, alsoon variable grasping abilities of the students, allof which are subjective.(3) Need for a

complementary platform to cater the educationas more objective tool associated with more oflearner’s control over it becomes evident on thisbackground. E-learning which is referred to as use of internetresources to deliver knowledge and skills(4) isbeing rampantly used in many leadinguniversities blending it with conventionalteaching learning activities(5). Specificallypertaining to medical education, e-learning canbe used to improve the efficiency and scope ofknowledge distribution towards students and atleast partially overcome the challenges listedabove. Additionally it can also be used as anefficient tool to explore many ever expandinghorizons of medical education includinggenomics, proteomics, evidence-based

11

FEASIBILITY OF APPLICATION OF E-LEARNING IN INDIANFIRST YEAR MEDICAL STUDENTS : STUDY TO ASSESS

INFRASTRUCTURE, SKILLS AND ATTITUDE

Dnyanesh B. Amle, Swati Hiwale, Gajendra Kumar Singh, P K PatraDepartment of Biochemistry, Pt. J. N. M. Medical College and

Dr. B. R. A. M. Hospital, Raipur, C.G., India

AbstractE-learning modalities are rampantly being used to overcome limitations and to supplementconventional teaching modes viz. lectures in many international and some Indian universities. AYUSHuniversity of Chhattisgarh is planning to implement e-learning module in first year MBBS students. Onthis ground, we aimed to assess the level of computer literacy and patterns of computer usage of first-year medical students, their attitude towards e-learning and thus feasibility of application of e-learningin an Indian scenario. Hundred first year medical students were recruited for the study of which 5backed out. 95 students were assessed with the help of detailed questionnaire regarding variousrelevant aspects including the availability of personal computer/Smartphone and internet facility,computer and Internet skills and attitude towards e-learning. Only 19% students were found to possessall necessary components needed to follow e-learning program regularly when laptop/computer isused as interface for e-learning, whereas75 (79%) students were found to possess all necessarycomponents if smartphones are used as interface for e-learning. We conclude that many students lackone or more of necessary components needed for successful implementation of e-learning viz.infrastructure and skills, but this hurdle can be overcome by using smartphone based e-learningmodule.

Keywords : E-learning, Attitude, Skill, Study Pattern


medicine, complementary medicine etc. duringunder-graduate curriculum. It being an objectiveplatform with user control, probabilities offorcefully burdening unwilling candidates withadditional knowledge stands cancelled(6).Though adapted by many of the well-knownuniversities across the world, few medicaluniversities from India have a well developedand monitored e-learning program. AYUSH andHealth Science University, Chhattisgarh state isset to be a pioneer in India regardingimplementing e-learning program forundergraduate medical students in all MedicalColleges of Chhattisgarh including Pt. J. N. M.Medical College, Raipur. In a developing countrylike India, where medical students come from allsocioeconomic strata of society, it is necessary toknow the profile of students and their attitudetowards e-learning. Unlike in developed world,Indian students who are not professionallyexposed to computers and laptops during schoolwill be at a particular disadvantage in the e-learning program. These inadequate skillsalong with technical infrastructure deficiency canvirtually impede course activity leading towidening of knowledge gap within studentsubsets. Those at the disadvantage can lagbehind their peers in this scenario of enormouscompetitive pressure.On this background, our study aims to assess thelevel of computer literacy and patterns ofcomputer usage of first-year medical studentsand their attitude towards e-learning. The studyalso aims to assess the feasibility of application ofe-learning in an Indian scenario.

Materials and MethodsThe study was conducted in Pt. JawaharlalNehru Memorial Medical College, Raipur,Chhattisgarh state and included cross-sectionalassessment of students based on a questionnaire.Hundred students from first year MBBS wererecruited for the study after obtaining informedwritten consent. Consent and protocol of thestudy were explained in detail to all the students

by the facilitator. Participation in the study wastotally optional and it was not mandatory forthem to enter in the study. Five students backedout from the study after filling consent form andhence ninety-five students participated in thestudy. All participants were given a detailedquestionnaire (supplement 1) regarding theirsocioeconomic status, availability of personalcomputer / smart phone and internet facility,computer skills and Internet skills, frequency ofusing computers and internet for differentpurpose, preferred pattern of learning in classand at home, previous experience with onlinelearning platforms and attitude towards e-learning. Some of the questions were leadingquestion and some were optioned. Due care wastaken to avoid exposure of teaching staff asfacilitator and students were given option toreveal or hide their identity during answering ofthe questionnaire.

Statistical AnalysisMean and standard deviation was used for toexpress age distribution and percentage wasused to express the frequency of various othervariables amongst students. Data was assessedwith Kolmogorov-Smirnov test for normaldistribution. Student’s t-test was used to assessAge distribution, Chi-square test for studyingfrequency of various categories of Best internetconnection, social network activity, computerskills and internet skills and Freeman-Haltonextension of the Fisher exact probability test wasused to study frequency of distribution in Bestgadget owned, Use of computer and internet forlearning and Preferred learning mode inclassroom. To record agreement of students tocertain sentences, data was collected on 8 pointLikert scale and then interpreted as 1-3: agree,4,5: can’t say, 6-8: disagree, as well as usingmedian and interquartile range. p-Value (twotailed) <0.05 was used as statistically significant.All statistical calculations were made using SPSSVersion 11 for windows (IBM Inc., Chicago, IL,USA)

E-learning in 1st year Medical Students 1313

ResultsThe characteristics of Study group are as shownin Table 1. Study population included a total of 54 maleand 41 female students. Best gadgets ownedwere categorized into personal computer / laptop(20%), shared computers / laptop (6%) andsmart phones (68%) (Fig. 1). Superiority ofgadget was considered as personalcomputer>shared computer>smart phone.Eighty-five students were found to possess smartphones. There was no significant difference(p=0.1) in the type of gadget owned in male andfemale student sub-groups. Best availableinternet connections were categorized as lowbandwidth which included 2nd generation (2G)internet connection (50%) and high bandwidthwhich included 3rd generation (3G) / wirelessfidelity (WiFi) / Dongle / Broadband connectionetc. (39 %). The category of internet connectiondiffers significantly between male and femalestudents (p=0.02). While access of internetconnection is higher in male students (92%)compared to females (85%), more females(62%) had access to high bandwidth comparedto male students (30%) (Fig. 2). Remarkablyhigh number of students from both (p=0.5)male (96%) and female (95%) were found to beactive on social networks.For assessment of status of skills to use e-learninginterface, they were questioned regarding levelof skills in computer / laptop / smart phone usein respect to various tasks and it was found that63% (64% of male and 61% of female) studentswere having sufficient skills for basic tasksneeded for e-learning interaction when usinglaptop / computer but 79% (80% male and 79%female) were found to be having sufficient skillsto use smart phone effectively for the samepurpose. It was also observed that 83% (87%male and 78% female) students possesssufficient internet skills for e-learning. (Fig. 3)It was found that only 18 (19%) students possessall, adequate gadget, internet facility and skills tofollow e-learning program regularly when laptop

/ computer is used as interface for e-learning(Fig. 4A). Whereas 75 (79%) students possessadequate gadget, internet facility and skills tofollow e-learning if smartphone is used as aninterface for e-learning (Fig. 4B).Study pattern of students was also assessed tohelp optimization of implementation of e-learning (Fig. 5).Fifty-four percent students were found to beusing computer or internet regularly forsupplementing their studies with a variablefrequency of daily (9.4%) weekly (26.3%) andmonthly (19%). It was found that 21% studentsstudy singly on their own while other 54% preferto do group study. 14% students regularly go tothe library while 18% go occasionally and 68%never go to library. Only 3% students knowabout computer and internet facility available inthe institute library. More students preferredblack-board (45%) over using power point (7%)in the classroom for teaching while 47% studentspreferred the combination of both. 22% studentsclaimed that they were conversant with e-learning in some form.Large subset of students (62%) supportedimplementation of e-learning to supplementconventional lectures (median=2, interquartilerange 2-3, ‘Agree’ on 8 point Likert scale), buteven more (74%) said that web-based learningprograms are not able to replace classroomteaching (median 7 IQR= 5-7, ‘Disagree’ on 8point Likert scale). Only 16% students agreedclearly to the statement that e-learning will createsense of insecurity in mediocre students while62% refused to accept this hypothesis(median=8, IQR=6-8, ‘Disagree’ on 8 pointLikert scale). In opposed to previous experience56 % students said that provision of free laptopwill enhance learning process and 12% wereagainst distribution of free laptops (median=4IQR=2-5, ‘Can’t say’ on 8 point Likert scale).

DiscussionResponse rate95 out of selected 100 students opted to


participate in study, this response rate (95%)closely resembles response rates in other studiescarried out in India and abroad(7,8,9,10).

Infrastructure and skillsOur institute is located in a non-metropolitan cityin the development phase. Barring a few citiesin India, most of the medical colleges are non-metropolitan cities and hence student populationof our institute is a better representative of themajority of the Indian medical students. Ourfindings must also be seen under the light of factthat most of the studies conducted in India havetargeted all medical undergraduates as well aspostgraduate students,(7,8,9,10). while our study isincluding only first year MBBS students. Aspostgraduate students are financially self-sufficient and they use laptops / computers formost of the postgraduate activities, chances ofthem bearing laptops / computers and necessaryskills are more and hence our study moreprecisely represents undergraduate medicalstudents.A large subset (74%) of the first-year medicalstudent in our institute still does not have accessto a personal computer and laptop, so they lackaccess to high-speed internet connection. Onlya few students (19%) were found compatible forlaptop / computer-based e-learning programwhile 79% students were found compatible withsmart phone based e-learning program. Thisobservation corresponds with findings byChhalla et al (Tirupati)(11). But it should also benoted that low bandwidth internet connection isa hurdle in the implementation of synchronous /interactive online communication tools like livediscussion sessions and extensive videos likerecording from classroom teaching. This limits e-learning program to the use of more of textualinformation and pictures to be successful(12).

Study patternE-learning program can be helpful to the subsetof students who use online materials tosupplement their studies (54%) for further

streamlining and efficiently using additionalonline material provided. Also, other studentswho are currently not using any of them can bemade interested about the same. Students whopreferred a combination of both conventionalblack-board and Power Point teaching can befurther benefited by providing them withmaterial like Power Point slides with anadditional explanation which is ready to accessanytime. E-learning can provide a platform for studentswho do not use library regularly for studying butprefer to study in groups (54%), for discussionon a particular topic, under supervision ofappointed faculty, these discussions can continueoffline. Such forums will help to streamline thediscussion and further it will be accessibleanytime for future use.

Attitude towards implementation of E-learningWillingness in the majority of students toparticipate in e-learning activities as asupplement to conventional teaching (62%) butnot as a replacement (74%) to conventionalteaching system was evident. Also, only 16%doubted that e-learning will cause a sense ofinsecurity in mediocre students indicating there isno negative attitude or concern regarding theimplementation of e-learning in the majority ofstudents. Support of students to distribution offree laptops was also noted, this specific findingshould be subjected to implementation strategiesonly after considering the fact that laptops usecan negatively impact students learning in classas seen in some previous studies(13,14).

ConclusionWe conclude that our study sample more closelyrepresents a large proportion of medical studentsin an Indian context. Many of these students lackat one or more of necessary components neededfor successful implementation of e-learning viz.infrastructure and skills, but this hurdle can beovercome by using smart phone based e-learning module. Study pattern of students can


be explored for the implementation of e-learningand can be successfully supplemented withvarious modes of e-learning. The majorities ofstudents are eager to supplement their studies

with online material and will respond positivelyto e-learning modules. Barring few studentsthere was no sense of insecurity regarding learning in others.

Table 1 : Characteristics of study group

Parameters Male Female P(n=54) (n=41) Value

Age 19.8±1.86 18.98±1.23 0.02

Best gadget owned Personal computer 11 8 0.1

Shared computer 5 1

Smart phone 37 28

Best internet connection 2G 35 13 0.02

3G/WiFi/Dongle/Broadband 15 22

Social network activity 52 39 0.5

Sufficient computer skills (laptop / p.c.) 35 25 0.8

Sufficient internet skills 47 32 0.3

Use computer &internet for learning Daily 7 2 0.4

Weekly 15 10

Monthly 8 10

Never 25 19

Preferred learning mode in classroom Black-board 29 14 0.01

Power Point 6 1

Combination 19 26


Figure 1 : Gadget availability in student groups (n)

Figure 2 : Internet availability with students (%)


Figure 3 : Students with compatible skills (%)

Figure 4 : Feasibility of implementing e-learning using computers / laptop (A) and smart phone (B) interface

17


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20

IntroductionThe prevalence of diabetes constituted chiefly bytype 2 diabetes is a global public health threat.The prevalence among adults aged 20-70 yearsis expected to rise from 285 million in 2010 to438 million by the year 2030(1). Since manyindividuals with type 2 diabetes mellituseventually require insulin treatment for controlof glycemia, the use of term NID DM (Non-Insulin dependent DM) generated considerableconfusion. Also type 1 DM most commonlydevelops before the age of 30, but anautoimmune beta cell destructive process candevelop at any age. Type 2 DM is aheterogenous group of disorders characterizedby variable degrees of insulin resistance,impaired insulin secretion and increased glucoseproduction(2). The physiology of C-peptide

makes it appropriate for assessing insulinsecretion. Insulin is produced in the pancreaticβ-cells by enzymatic cleavage of the prohormoneprecursor proinsulin to produce insulin and C-peptide in equimolar amounts. C-peptide hasnegligible extraction by the liver and constantperipheral clearance. Its half-life is longer thaninsulin (20–30 vs. 3–5 min) and it thereforecirculates at concentrations approximately fivetimes higher in the systemic circulation. The keycurrent clinical role of C-peptide is to assistclassification and management of insulin treatedpatients(3). C-peptide levels are also used todiscriminate between autoimmune and non-autoimmune diabetes(4). This study was con-ducted to correlate fasting plasma insulin and C-peptide levels in patients with type 2 diabetesmellitus.

CORRELATION OF FASTING PLASMA INSULIN AND C-PEPTIDELEVELS IN PATIENTS WITH TYPE 2 DIABETES MELLITUS

Maninder Kaur, Maninder Sandhu, Gurdeep Kaur Bedi,Raminderpal Singh Sibia

Department of Biochemistry, Govt. Medical College and Rajindra Hospital, Patiala, Punjab - 147001

AbstractType 2 DM (Diabetes Mellitus) is characterized by hyperglycemia due to insulin resistance and relativeinsulin deficiency. The aim of this study was to estimate insulin and C-peptide levels in Type 2 diabeticpatients and to find the correlation with each other, with body mass index (BMI) and duration of DM.Insulin is synthesized in the β cells of pancreas as proinsulin which is processed to form C-peptideand insulin, and both are secreted in equimolar amounts. C-peptide has a 2-5 times longer half-lifethan insulin and these levels fluctuate less than insulin and reflect pancreatic insulin secretion morereliably than the level of insulin itself. Also C-peptide determinations are disturbed to a lesser extentthan insulin measurements by the presence of insulin binding antibodies. Until the development of C-peptide assays, evaluation of β cell function in insulin treated patients was impossible as the insulinassay is unable to discriminate between secreted and injected insulin. 60 diagnosed patients of DMand 25 healthy controls were recruited in our study. Significant positive correlation was seen betweeninsulin and C-peptide levels. Also a significant positive correlation was observed when both parameterswere related to body mass index (BMI). Both in Insulin and c-peptide levels were increased withincrease in BMI. Significant negative correlation was seen in Insulin and C-peptide levels with durationof diabetes i.e. as the duration of DM increased, Insulin and C-peptide levels decreased.

Keywords : Type 2 DM (Diabetes Mellitus), Insulin, C-peptide, BMI (Body Mass Index)

Plasma Insulin and C-peptide levels in type 2 DM 2121

Materials and Methods The present study was conducted in Departmentof Biochemistry at Govt. Medical College, Patialaon 60 diagnosed cases of type 2 DM referred byDepartment of Medicine, Rajindra Hospital,Patiala. 25 age and gender- matched healthyindividuals constituted the control group.Informed consent of all subjects and detailedhistory were taken at the beginning of the study.The research work was granted and approvedby Faculty of Medical Sciences, Baba FaridUniversity of Health Sciences, Faridkot (Punjab)

Exclusion Criteria: Following patients wereexcluded from the study-

• with diabetic ketoacidosis• on anticonvulsant therapy• with renal diseases• with eye diseases

Fasting venous blood samples, under asepticconditions, were collected in EDTA vials andfollowing parameters were estimated in casesand controls.

Parameter Normal RangeFasting Plasma Glucose(FPG) : 60-100mg%Fasting Plasma Insulin(FPI) : 0.7-9.0μIU/ml

Fasting Plasma C-Peptide(FPCP) : 0.7-1.9ng/mlBody Mass Index(BMI) : Less than 25kg/m2

• Fasting Plasma Glucose (FPG)level wasestimated by Glucose Oxidase method

• Fasting Plasma Insulin (FPI) level wasestimated by ELISA method

• Fasting Plasma C-peptide (FPCP) levelswas estimated by ELISA method

• Body Mass Index (BMI) was calculatedusing Quetlet’s index

Result :Investigation results are represented in Table 1,2, 3, 4

Statistical AnalysisStatistical analysis was performed usingStatistical Package for Social Sciences (SPSS).Mean and Standard Deviations (SD) werecalculated for all parameters. The independentsample t-test was used to compare the mean ofdifferent variables in the two groups. In addition,the Pearson correlation coefficient (r) was usedfor correlation analysis. P value <0.05 wasconsidered significant.

DiscussionThe mean age in the present study was55.68±10.19 years with an urbanpreponderance (68.3% patients from urbanarea). This could be attributed to westernizationof life style in urban areas which may includeconsumption of junk foods etc. Mean BMI in thestudy group was increased (27.3±6.16 kg/m2)and this could be due to the association ofobesity with insulin resistance and type 2diabetes mellitus. The Mean Fasting PlasmaInsulin in study group was increased(20.96±15.25 μIU/ml) which is probably due toinsulin resistance. In the early stages of thedisorder, glucose tolerance remains near-normal,despite insulin resistance, because the pancreaticbeta cells compensate by increasing insulinoutput(5). The Mean Fasting Plasma C-Peptide instudy group was increased (2.6±2.2ng/ml). Thiscan be explained by co-secretion of c-peptidewith insulin in equimolar amounts from beta cellsof pancreas. The Mean serum triglycerides(S.TG) in study group were increased(149.25±70.2 mg%.) A positive correlation offasting plasma glucose levels with serumtriglycerides was observed which was statisticallysignificant (p=.009) in our study group. As aresult of insulin resistance in adipose tissue,lipolysis and free fatty acid flux from adipocytesis increased, leading to increased lipid[triglyceride] synthesis in hepatocytes(5).

BMI =Weight (kg)Height (m)2

Table 1 : Comparison of FPG, FPI, FPCP levels and BMI in the study and control group

Mean±SD of the Group t p S

Parameter Study Group Control Group Value Value Significance

<FPG (mg%) 162.62±35.305 77.56±11.158 11.767 <0.001 HS

BMI(kg/m2) 27.3±6.16 24.19±2.05 2.459 .016 S

Fasting Plasma Insulin(μIU/ml) 20.96±15.25 5.87±1.79 4.914 <.001 HS

Fasting Plasma C-peptide 2.6±2.2 1.47±0.31 2.525 .013 HS(ng/ml)

FPG, FPI, FPCP levels were significantly increased in the study group as compared to the control group


Correlation of fasting plasma Insulin levels withfasting plasma C-peptide levels was positive andhighly significant in our study group withPearson correlation coefficient, (r)=.869 andp<.001. This is because after cleavage ofproinsulin, the intact C-peptide is stored withinsulin in the soluble phase of the secretorygranules and is subsequently released inequimolar amounts with insulin, providing auseful independent indicator of insulinsecretion(6).Correlation of fasting plasma Insulin and C-peptide levels with BMI was positive (i.einsulin and C-peptide levels were increased inthose patients with increased BMI ) and wasstatistically highly significant in our study groupwith r=.815 and p<.001. This is probably dueto changes in the secretion or sensitivity to leptinand adiponectin in obesity. Leptin andadiponectin play a significant role in theregulation of lipid and carbohydrate metabolism.Adiponectin increases insulin sensitivity in boththe liver and skeletal muscle. Leptin decreasesappetite, increases energy expenditure,suppresses insulin synthesis and secretion andincreases insulin sensitivity(7). A negativecorrelation between fasting plasma Insulin and

c-peptide levels with duration of DM was seeni.e with progression of diabetes mellitus, insulinand C-peptide levels decreased. This wasstatistically highly significant in our study group.[r = -.558 and p< .001] This could be probablydue to progressive deterioration of beta cellfunction in diabetic patients with increasingduration of diabetes.

ConclusionC-Peptide is produced in equal amounts toinsulin and can therefore be used to assessendogenous insulin secretion. Insulin producedby pancreas is extensively first pass metabolizedby the liver. The extent of first pass metabolismand peripheral clearance of insulin is variable,therefore peripheral insulin levels may notaccurately reflect portal insulin secretion.Peripheral C-peptide levels more accuratelyreflect portal insulin secretion than measurementof peripheral insulin. C-peptide measurementwhich is relatively inexpensive is commonly usedin preference to insulin measurement especiallyin patients on insulin therapy becauseexogenous insulin will also be detected by insulinassays.

Table 2 : Correlation of FPI with FPCP, BMI and duration of DM in study group FPI levels(μIU/ml)

Parameter r Value p Value Significance S

FPCP (ng/ml) + .869 <.001 HS

BMI (kg/m2) + .815 <.001 HS

Duration of DM (years) - .558 <.001 HS

FPI and FPCP had a positive correlation i.e. as FPI increased, FPCP also increased FPI and BMI had a positive correla-tion i.e. FPI was increased in patients with increased BMI. FPI and duration of diabetes had a negative correlation i.e. as duration of diabetes increased, FPI levels were decreased.

Table 3 : Correlation of FPCP with FPI, BMI and duration of DM in study group

FPCP levels (ng/ml)

Parameter r Value p Value Significance

FPI (μIU/ml) + .869 <.001 HS

BMI (kg/m2) + .916 <.001 HS

Duration of DM (years) - .510 <.001 HS

FPI and FPCP had a positive correlation i.e. as FPI increased, FPCP was also increasedFPCP and BMI had a positive correlation i.e. FPCP was increased in patients with increased BMIFPCP and duration of diabetes had a negative correlation i.e. FPCP levels decreased with increasing duration of diabetes.

Table 4 : Comparison of Serum TGs in study and control group

Parameter Group Number of Range Mean±SD P Spatients (mg%) (mg%)

S.TG Study 60 54-352 149.25±70.2 <.001 HS

(mg%) Control 25 56-102 79.96±14

The mean Triglycerides in the study group were 149.25±70.2 mg% and in the control group were 79.96 ±14.6 mg%.On statistical analysis, the difference was found to be highly significant (p<0.001).

Plasma Insulin and C-peptide levels in type 2 DM 2323

Reference1. Ramachandran A, Snehalatha C, Shetty AS, Nanditha

A. Trends in prevalence of diabetes in Asian countries.World J Diabetes 2012 Jun 15;3(6):110-7

2. Powers A C. Diabetes mellitus.Harrison Principles ofinternal medicine. 18th ed. McGraw Hill; 2012 : 2968-3003

3. A G Jones, AT Hattersley. The clinical utility of C –peptide measurement in the care of patients withdiabetes. Diabetic Med 2013 Jul; 30 (7) : 803-817.

4. Thunander M, Tom C, Petersson C, Ossiansson B,Fornander J, Olsson M L. Levels of C-peptide,body

mass index and age and their usefulness inclassification of diabetes in relation to autoimmunity,inadults with newly diagnosed diabetes in Kronoberg,Sweden. Eur J Endocrinol 2012 Jun;166(6): 1021-1029

5. Powers AC. Diabetes mellitus. In Harrison Principle ofinternal Medicine eds. United state of America; McGraw –Hill; 2005;16:2154-2158

6. Steiner DF The proinsulin C-peptide--a multirolemodel. 2004 Jan-Mar;5(1):7-14.

7. Huerta MG. Adiponectin and leptin: potential tools inthe differential diagnosis of pediatric diabetes. RevEndocr Metab Disord 2006; 7(3): 187-96.

IntroductionThe results of the laboratory diagnostic tests playan important role in clinical decision making andform an indispensible part of health care. Theerrors that can affect these results in thelaboratory may be pre-analytical, analytical andpost-analytical. We usually focus on analyticalerrors, although pre-analytical errors (improperblood drawing technique, incorrect timing ofsample collection, wrong tube for collection, in-vitro haemolysis, lipemic sample etc.) alwaysinfluence the total error and consequently, thediagnostic accuracy(1). The pre-analytical phaseis subject to the maximum number of accidentsand uncertainty. Hence, this phase accounts foran important part of laboratory diagnostics’testing and quality management. The rate ofoccurrence and the type of such errors must be

properly documented in every laboratory andcorrective measures should be designed andimplemented accordingly. In order to minimizethese errors, continuous training of thelaboratory personnel, along with the MBBSstudents, medical interns and the clinicians, ismandatory. When this is practiced continuouslyby laboratories, it will help in ensuring the qualityof the results of these tests and will have apositive role in improving patient care. Van Ments (1989) defines role play as: "oneparticular type of simulation that focusesattention on the interaction of people with oneanother. It emphasises the functions performedby different people under various circumstances.The idea of role-play, in its simplest form, is thatof asking someone to imagine that they areeither themselves or another person in a

24

ADOPTING ROLE PLAY FOR TRAINING MEDICAL INTERNS ABOUT SAMPLE COLLECTION AND PROCESSING

FOR LABORATORY INVESTIGATIONS

Mohit Mehndiratta, Dinesh PuriDepartment of Biochemistry, University College of Medical Sciences

Delhi - 110095

AbstractBackground: Role-play is a recommended tool for imparting medical education. It is now widelyadopted in many medical institutes but there is little published evidence on its use in pre clinicalsubjects. There are three phases in the generation of reports of laboratory investigations: the pre-analytical (selection of test, sample collection etc), the analytical (analysis of the sample by thelaboratory) and the post analytical phases (reporting and interpretation of results). Errors mostcommonly occur in the pre-analytical phase and thus, may affect the accuracy of the reports of theinvestigations. The study is designed to use role play to acquaint medical interns with the errors that may arise duringthe pre-analytical phase and how to avoid them.Different scenarios encountered in the pre-analytical phase like the technique for drawing blood, thetiming of sample collection etc. were presented before medical interns (n=64), along with theiroutcomes / implications. Semi-formal feedback was taken at the end of the session.This work describes how to use role play for teaching about pre-analytical errors. Students found itmore stimulating than the usual methods and were able to correlate better with the actual situationsthey will encounter while dealing with patients.

Keywords : Medical Interns, Sample collection, Lab. Investigation

Role Play for Training of Medical Interns 2525

particular situation. They are then asked tobehave exactly as they feel that person would.As a result of doing this they, or the rest of theclass, or both, will learn something about theperson and/or situation. In essence, each playeracts as part of the social environment of theothers and provides a framework in which theycan test out their repertoire of behaviours orstudy the interacting behaviour of the group"(2).Studies have been done to explore students'experiences about role play and to developguidelines for maximising its benefits in medicaleducation(3). Stimulation plays an important rolein many fields of medical education and hasoften been used in communication training. Areport has suggested its use for training intechnical clinical skills and sessions with role-playing were rated significantly higher thansessions without role-playing(4). Many studieshave highlighted its importance andrecommended the use of role-play as anessential part of the curriculum in medicaleducation(5,6). In our institute, medical students are taughtabout pre-analytical errors during their first yearof training and again at the beginning ofinternship. Role-play has never been used as aneducational method for this purpose. The usualmethod of teaching is a didactic lecture. Here,we describe in detail how to use role play as amethod of teaching about reduction of pre-analytical errors.

Materials and MethodsWe designed our presentation for the training ofmedical interns (medical students after they passMBBS exam (graduate) undergo one year oftraining in various clinical departments to gainpractical experience) regarding “Yourcontribution towards valid results (bylaboratory)” utilizing role play as a teachingmethod. This was a routine teaching session asa part of the currently practiced curriculum fortraining medical interns. We covered thefollowing aspects- improper technique of

drawing blood, incorrect timing of samplecollection, wrong tube for collection and in-vitrohaemolysis. Appropriate props were also utilized.Four teachers were involved during thepresentation. One person acted as a narratorand moderator, one each as “Dr Bad” and “DrGood” and one person acted as a patient.Various, pre-decided scenarios were presentedbefore the medical interns, one by one. Eachscenario was divided into two parts where boththe correct (involving Dr Good) and the incorrect(involving Dr Bad) methods were demonstrated.The outcomes of both the correct and incorrectmethods were presented to the medical internsand their implications were discussed (Table 1).Semi-formal feedback was taken from thestudents in the form of a discussion (as weusually have at the end of a routine lecture) tocompare this with the usual method of teaching(didactic lecture). In order to document theeffectiveness of the method five interns wererandomly chosen later from amongst those whowere trained. They were interviewed in a nonformal manner in their work place.

Results and Discussion64 interns were to attend this session and all ofthem participated (percentage=100). Role playpromotes active learning amongst students.Planned and structured role plays can be usedto deliver the components of a curriculum,particularly in clinical rotations of a medicalprogramme. Useful tips to create a meaningfullearning experience for students using role playhave been published(7). We applied this methodof role play for teaching medical interns aboutthe errors that may arise in the pre-analyticalphase (pre-analytical variables). Through thiswork we would like to emphasise how thismethod is better than didactic lectures in thisregard. The medical interns trained by us were ofthe opinion that this method is stimulating,thought provoking and lively than the usualmethod of teaching. They would be able tocorrelate better with the actual situations they will

Table 1: Various scenarios that were presented via role play before the medical internswith their outcomes / implications:

What Dr Bad did

Sample collected for serumcalcium estimation.Tourniquet left on the armfor too long (3 minutes),while the Dr attended aphone call.

Sample for blood glucoseestimation collected at nightand left at roomtemperature. Sent to thelaboratory in the followingmorning.

Sample for estimation ofelectrolytes (potassium andsodium) collected in a tubecontaining Potassium salt ofEDTA

Sample for estimation ofblood glucose collected in aplain tube (serum vial)

•Blood sample transferredto the collection vial directlyfrom the syringe via aneedle attached to it.• Samples were shakenvigorously for mixing withthe anticoagulant.

What Dr Good did

Sample collected for serumcalcium estimation.Tourniquet used briefly(kept on the arm tillsampling is complete)

Sample for blood glucoseestimation collected in themorning and sent to thelaboratory immediately.

Sample for estimation ofelectrolytes (potassium andsodium) collected in a plaintube (serum vial)

Sample for estimation ofblood glucose collected in aFluoride vial

•Blood sample transferredto the collection vial directlyfrom the syringe withoutneedle.•Samples were mixed withthe anticoagulant by tiltingand rotating the tube gently.

Outcomes / Implications

Dr Bad: False high serumcalcium levelsDr Good: Results reflectedthe true value for serumcalcium

Dr Bad: False low value forblood glucoseDr Good: Results reflectedthe true value for bloodglucose

Dr Bad: False highpotassium levels (notcompatible with life)Dr Good: Results reflectedthe true value for serumelectrolytes

Dr Bad: False low value forblood glucoseDr Good: Results reflected thetrue value for blood glucose

Dr Bad: sample ishaemolysed and results infalse low/high values for theparameters measuredDr Good: Results reflectedthe true value for theparameters measured

Scenarios

Improper blooddrawing technique

Incorrect timingof sample

Wrong tube forcollection

Wrong tube forcollection

In-vitro haemolysis


encounter in the future. The primary limitationof the method is that fewer topics can be coveredin the given time. The students were also notdirectly involved in this session. To overcome thiswe are planning an active involvement of thestudents in future role playing sessions. Duringassessment at the work place, it was found thatall medical interns were taking the correctprecautions while collecting and sending theblood samples for analysis to the laboratory, thusensuring better quality of results.

ConclusionThis paper describes how to use role play as ateaching methodology in the preclinical setup.The lesson learnt from our experience is that thecreation and the use of simulated situationsutilizing role play as a teaching method is a farmore beneficial and innovative way of makingmedical interns understand the precautions thatshould be taken to minimize pre-analyticalerrors. The methodology described in this papercan also be adopted to teach other proceduresand practices to medical students.

Role Play for Training of Medical Interns 2727

Reference

1. Lippi G, Blanckaert N, Bonini P, Green S, Kitchen S,Palicka V, Anne JV, Camilla M, Plebani, M.. Causes,consequences, detection, and prevention ofidentification errors in laboratory diagnostics. Clinicalchemistry and laboratory medicine,2009;47(2):143-153.

2. Van Ments M.1989. The Effective Use of Role Play: AHandbook for Teachers and Trainers, New York:Nichols Publishing.

3. Nestel D, Tierney T. Role-play for medical studentslearning about communication: Guidelines formaximising benefits. BMC Medical Education.2007;7(1):3.

4. Nikendei C, Zeuch A, Dieckmann P, Roth C, Schäfer

S, Völkl M., Schellberg D, Herzog W, Jünger J. Role-playing for more realistic technical skillstraining.Medical teacher, 2005;27(2):122-126.

5. Caroline F, Gibbs J, Eisen S. Video improved role playfor teaching communication skills. Medical education.2005;39.11:1155-1156.

6. Dieckmann, P., Rall, M., Eich, C., Schnabel, K.,Jünger, J., & Nikendei, C. (2007). [Role playing as anessential element of simulation procedures inmedicine]. Zeitschrift fur Evidenz, Fortbildung undQualitat im Gesundheitswesen, 2007;102(10):642-647.

7. Beres Joyner and Louise Young.Teaching medicalstudents using role play: Twelve tips for successful roleplays. Medical teacher.2006;28:225-229.

28

IntroductionChronic kidney disease (CKD) is an emerginghealth problem and has significant morbidityand mortality(1). Mineral and bone disorders arecommon in CKD and are now collectivelyreferred to as Chronic kidney disease- mineraland bone disorder (CKD-MBD)(2). Abnormalitiesin vitamin D metabolism play a major role in thepathogenesis of secondary hyperparathyroidismin chronic kidney disease leading to majorclinical and research implications(3). Hence, it isessential for early detection, evaluation,diagnosis and treatment of this condition.In healthy individuals vitamin D is initiallysynthesized in the skin or acquired via the diet.This provitamin D is then hydroxylated to 25-hydroxy vitamin D [25(OH)D] in the liver and isfurther converted to1, 25-dihydroxy vitamin Dby 1-alpha-hydroxylase in the kidney. 1, 25-dihydroxy vitamin D [1,25(OH)2D] also knownas Calcitriol is the active form of vitamin D isresponsible for calcium absorption from the

intestine(4). CKD is associated with renaldysfunction which results in impaired conversionof 25-hydroxy vitamin D to 1,25-dihydroxyvitamin D. Further, as kidney function declines,phosphorus excretion is reduced, causing plasmaphosphorus levels to rise while plasma calciumand calcitriol levels decrease. All of these factorscontribute to the development of hypocalcemia,which results in increased production of PTH.Fibroblast growth factor-23 (FGF-23) increasesearly in the course of CKD possibly as aconsequence of phosphorus retention, alsosuppresses calcitriol synthesis, in turn leading toincreased PTH(5). Secondaryhyperparathyroidism in turn leads to renalosteodystrophy, vascular and soft tissuecalcification and is associated with increased riskof adverse cardiovascular outcomes and death(6).Therefore, elevated PTH andhyperphosphatemia are identified as major riskfactors for morbidity and mortality in CKDpatients(7).

STUDY OF SERUM VITAMIN D AND PARATHYROID HORMONELEVELS IN CHRONIC KIDNEY DISEASE PATIENTS

Anita1, Seema Patel1, B. C Kabi1, Karthik T2, Vindu Amitabh2

1Department of Biochemistry, 2Department of MedicineVardhman Mahavir Medical College (VMMC) and Safdarjung Hospital (SJH)

New Delhi, India

AbstractChronic kidney disease (CKD) is a modern day global epidemic and it is now recognized as a publichealth issue. Despite recent therapeutic advances, mortality remains high among patients with chronickidney disease. Therefore it is strongly recommended to monitor serum levels of calcium, phosphorus,Vitamin D and Parathyroid hormone (PTH) in these patients. In the present study we found that themean 25 hydroxy vitamin D level was found to be 41.09ng/ml in control subjects and 21.6ng/ml incases (patients with CKD stage 3-4). Mean PTH level was found to be 32.23 pg/ml in controls and314.9 pg/ml in cases. Mean calcium levels were 7.6 mg/dl in cases and 10mg/dl in control andPhosphorus level 4.8 ± 0.7 mg/dl in cases and 3.3mg/dl in control respectively. Severe secondaryhyperparathyroidism is associated with morbidity and mortality in patients with CKD. Hence, VitaminD supplementation may prove as recommended modality for prevention and treatment ofhyperparathyroidism in these patients.

Keywords : CKD, PTH, CKD-MBD

Serum Vit. D and PTH levels in CKD 2929

Bone biopsy is gold standard for the precisediagnosis of renal bone disease however it isinvasive. Hence, the clinician should evaluatetrends in biochemical markers as a part of anintegrated and comprehensive assessment andto guide the treatment of chronic kidney diseasepatients. The present study was undertaken todetermine the vitamin D, calcium, phosphorus,Parathyroid hormone status of Indian CKDpatients in stage 3-4.

Materials and MethodsStudy DesignThe study was conducted in the departments ofMedicine and Biochemistry, Vardhman MahavirMedical College & Safdarjung Hospital, NewDelhi. The study included 50 patients and wasconducted after institutional ethical committeeapproval and informed consent was taken fromboth cases and controls. Age and sex matchedhealthy controls were included in the study.Cases included in the study were: adult patientswith CKD stage 3-4 as defined by KDOQIguidelines. Criteria for exclusion included;(1) anyunderlying medical condition, such asmalabsorption syndrome or severe liver disease,that might alter the absorption or metabolism ofvitamin D, (2) Primary Parathyroid disease orparathyroid surgery within the previous 12months, (3) vitamin D deficiency disease.Blood samples were collected for calcium,phosphorus, 25-hydroxy vitamin D, and PTHanalysis. Measurement of calcium was done byO-Cresolphthalein Complexone method,phosphorus by phoshomolybdate reduction bykits (DRG diagnostics, USA). 25-hydroxyvitamin D and iPTH levels were measured byEnzyme linked immunosorbent assay by ELISAKit (Calbiotech, California, CA). The labreferences were 10–65 pg/ml for iPTH, 10–65ng/ml for 25-hydroxy vitamin D, 8.5-10.5 mg/dlfor calcium, 3-4.5 mg/dl for phosphorus.

Statistical analysisThe data were expressed as mean±SD. Student

t-test was used to test for significance. A value ofP<0.05 was considered significant.

ResultsPatients were analyzed for their 25-hydroxyvitamin D, calcium, phosphorus and parathyroidhormone (PTH) status. The baselinecharacteristics of the study group were as shownin [Table - 1]. Twenty-seven (54%) patients werefound to have diabetic nephropathy, fifteen(30%) hypertensive and 8 (16%) patients bothdiabetic and hypertensive (Fig. 1). 25-hydroxyvitamin D level ranged from10 to 31 ng/ml.Further it was seen that only 6 (12%) patientswere vitamin D sufficient (>30ng/ml) and 42(84%) were vitamin D insufficient (21-30ng/ml)(Fig. 2). The remaining 2 (4%) were vitamin Ddeficient (11-20ng/ml). Patients were labeledvitamin D insufficient if the levels were between20 and 30 ng/ml and deficient if the levels wereless than 20 ng/ml(3). The mean Vitamin D levelwas found to be 41.09±0.5 ng/ml in controlsubjects and 21.60±0.46 ng/ml in cases(patients with CKD stage 3-4). PTH levelsranged from 87 to 566 pg/ml. Similarly meanPTH level was found to be 32.23±0.8 pg/ml incontrols and 314.9±0.76 pg/ml in cases. Meancalcium, phosphorus were 7.6±0.64 mg/dl,4.8±0.7 mg/dl in cases and 10±0.78 mg/dl and3.3±0.9 mg/dl in control respectively [Table 2].Vitamin D level was significantly low and PTHlevel was significantly high in cases, patients withCKD compared to controls. Serum calcium levelwas significantly low and serum phosphoruslevel was significantly high in cases as comparedto control.

DiscussionChronic kidney disease (CKD) is emerging to bean important disease globally(8) due to rapidlyincreasing worldwide incidence of diabetes(9) andhypertension(10,11). The rising incidence of thisdisease is likely to pose major problems for bothhealthcare and the economy in future years.Recently in India, it has been estimated that the


age-adjusted incidence rate of ESRD was foundto be 229 per million population and >100,000new patients enter renal replacement programsannually(12). Hence, early detection of kidneydisease through screening programs may help inretarding the progression of kidney disease. In the present study we found a significantdecrease in serum 25-hydroxy vitamin D levels(mean 21.6ng /ml) and an associated increase inPTH levels (mean 314.9 pg /ml) alongwithdecrease in calcium and associated increase inphosphorus level. Numerous studies havereported varying vitamin D deficiency in CKDwith prevalence rates of 70% to 80% in someparts of the world (13,14,15). Similarly studies havereported high prevalence of Vitamin D deficiencyin kidney disease patients in India(4,16,17).Reduced sun exposure(18), impaired skinsynthesis of cholecalciferol(19), hyperpigmen-tation seen in late CKD stages(20) and dietaryrestrictions advised to these patients contributeto high prevalence of vitamin D deficiency.Besides, there are a number of other factors thatare responsible for downregulation of renal 1-αhydroxylase in CKD which includeshyperphosphatemia, FGF-23, acidosis,hyperuricemia(21, 22, 23). As CKD progresses, thereis a decrease in the number of vitamin Dreceptors (VDR) and calcium receptors (CaR)which makes the parathyroid glands moreresistant to calcitriol and calcium. Phosphorusalso induces hyperplasia of the parathyroidglands by a post transcriptional mechanism andincreases PTH synthesis and secretion(24).Furthermore, secondary hyperparathyroidismand elevated FGF-23 lead to degradation of25(OH) vitamin D by promoting the enzyme 24-hydroxylase to form 24,25-dihydroxy vitamin

D(25) leading to 25-OH Vitamin D deficiencythereby corroborating the findings in the presentstudy.These findings strongly support the importanceof an early diagnosis of mineral homeostasisdisorders in CKD and the need for a correctionof vitamin D deficiency to prevent thecomplications. Hence, repletion of vitamin Dstores should be accomplished usingcholecalciferol (vitamin D3) or ergocalciferol(vitamin D2) and should target a serum 25-hydroxyvitamin D level>30 ng/mL, PTH level<70pg/mL for stage 3 CKD patients or <110pg/ml for stage 4 CKD patients and it alsorequires monitoring of serum calcium andphosphorus levels(26).Vitamin D has proved its significance inpreventing secondary hyperparathyroidism inchronic kidney disease patients highlighting theimportance of early diagnosis of altered VitaminD metabolism in CKD. So, Vitamin Dsupplementation may prove as recommendedmodality for prevention and treatment ofhyperparathyroidism in these patients. Hence it’stime for nephrologists, endocrinologists,nutritionists and public health agencies topropagate and implement updated guidelinesand recommendations to halt the growingepidemic of vitamin D deficiency, particularly inthe highly susceptible CKD population.

AcknowledgementWe gratefully acknowledge all the participants fortheir contribution in the present study. We alsoacknowledge physicians and staffs inDepartment of Medicine and Biochemistry inVMMC and SJH, New Delhi.

Case Control P value

Age( yrs) 39.1±10.7 33.1±7.9

Blood urea(mg/dl) 122.8±10.7 30.2±7.3 P<0.01

Serum Creatinine(mg/dl) 8.9±1 0.6±0.2 P<0.01

GFR (ml/mt/1.73m2) 36.1±1 126.4±11.59 p<0.01

Hemoglobin(g/ dl) 10.4 ± 0.45 12.4±0.5 p<0.01

Albumin(g/dl) 3.6±0.62 6.8±0.9 p<0.05

Fig. 2: Distribution (pie chart) of VitaminD level in study population.

Fig.1: Distribution (pie chart) of diabetesand hypertension in the study

population.

Table 1: Baseline characteristics of the study group



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6. Ketteler M, Bongartz P, Westenfeld R, Wildberger JE,Mahnken AH, Böhm R, et al. Association of low fe-tuin-A (AHSG) concentrations in serum with cardio-vascular mortality in patients on dialysis: across-sectional study. Lancet. 2003 Mar8;361(9360):827–33.

7. Abe M, Okada K, Soma M. Mineral Metabolic Abnor-malities and Mortality in Dialysis Patients. Nutrients.2013 Mar 22;5(3):1002–23.

8. Ruggenenti P, Schieppati A, Remuzzi G. Progression,remission, regression of chronic renal diseases. Lancet.2001 May 19;357(9268):1601–8.

9. Wild S, Roglic G, Green A, Sicree R, King H. Globalprevalence of diabetes: estimates for the year 2000and projections for 2030. Diabetes Care. 2004May;27(5):1047–53.

10. Gupta R. Trends in hypertension epidemiology inIndia. J Hum Hypertens. 2004 Feb;18(2):73–8.

11. Anand MP. Prevalence of hypertension amongstMumbai executives. J Assoc Physicians India. 2000Dec;48(12):1200–1.

12. Singh AK, Farag YMK, Mittal BV, Subramanian KK,Reddy SRK, Acharya VN, et al. Epidemiology and riskfactors of chronic kidney disease in India - results fromthe SEEK (Screening and Early Evaluation of KidneyDisease) study. BMC Nephrol. 2013;14:114.

13. Kandula P, Dobre M, Schold JD, Schreiber MJ,Mehrotra R, Navaneethan SD. Vitamin D Supple-mentation in Chronic Kidney Disease: A SystematicReview and Meta-Analysis of Observational Studiesand Randomized Controlled Trials. Clin J Am SocNephrol. 2011 Jan;6(1):50–62.

14. LaClair RE, Hellman RN, Karp SL, Kraus M, Ofner S,Li Q, et al. Prevalence of calcidiol deficiency in CKD:a cross-sectional study across latitudes in the UnitedStates. Am J Kidney Dis. 2005 Jun;45(6):1026–33.

15. Bhan I, Burnett-Bowie S-AM, Ye J, Tonelli M, Thad-hani R. Clinical Measures Identify Vitamin D Defi-ciency in Dialysis. Clin J Am Soc Nephrol. 2010Mar;5(3):460–7.

16. Jabbar Z, Aggarwal PK, Chandel N, Kohli HS, GuptaKL, Sakhuja V, et al. High prevalence of vitamin D de-ficiency in north Indian adults is exacerbated in thosewith chronic kidney disease. Nephrology (Carlton).2009 Apr;14(3):345–9.

17. Aggarwal M, Sahoo S, Bhandari H, Kriplani J, MithalA. Prevalence of vitamin D deficiency in post renaltransplant patients. Indian Journal of Endocrinologyand Metabolism. 2012;16(2):274.

18. Obi Y, Hamano T, Isaka Y. Prevalence and PrognosticImplications of Vitamin D Deficiency in Chronic Kid-

Serum Parameters Cases Controls P value

Serum Calcium(mg/dl) 7.6 ± 0.64 mg/dl 10±0.78 mg/dl <0.001

Serum Phosphorus(mg/dl) 4.8 ± 0.7 mg/dl 3.3±0.9 mg/dl <0.001

Serum 25(OH) Vitamin D(ng/ml) 21.60± 0.46 ng/ml 41.09± 0.5 ng/ml <0.001

Serum PTH(pg/ml) 314.9±0.76 pg/ml 32.23±0.8 pg/ml <0.001

Table 2 : Serum levels of calcium, phosphorus, 25 (OH) Vitamin D and PTH in cases andcontrols


ney Disease. Disease Markers. 2015 Mar 26; 2015 :e868-961.

19. Jacob AI, Sallman A, Santiz Z, Hollis BW. Defectivephotoproduction of cholecalciferol in normal and ure-mic humans. J Nutr. 1984 Jul;114(7):1313–9.

20. Abdelbaqi-Salhab M, Shalhub S, Morgan MB. A cur-rent review of the cutaneous manifestations of renaldisease. J Cutan Pathol. 2003 Oct;30(9):527–38.

21. Hsu CH, Vanholder R, Patel S, De Smet RR, SandraP, Ringoir SM. Subfractions in uremic plasma ultrafil-trate inhibit calcitriol metabolism. Kidney Int. 1991Nov;40(5):868–73.

22. Takahashi S, Yamamoto T, Moriwaki Y, Tsutsumi Z,Yamakita J, Higashino K. Decreased serum concen-trations of 1,25(OH)2-vitamin D3 in patients withgout. Metab Clin Exp. 1998 Mar;47(3):336–8.

23. Gutierrez O, Isakova T, Rhee E, Shah A, Holmes J,Collerone G, et al. Fibroblast growth factor-23 miti-gates hyperphosphatemia but accentuates calcitrioldeficiency in chronic kidney disease. J Am SocNephrol. 2005 Jul;16(7):2205–15.

24. Slatopolsky E, Brown A, Dusso A. Pathogenesis ofsecondary hyperparathyroidism. Kidney Int Suppl.1999 Dec;73:S14–9.

25. Shimada T, Hasegawa H, Yamazaki Y, Muto T, HinoR, Takeuchi Y, et al. FGF-23 is a potent regulator ofvitamin D metabolism and phosphate homeostasis. JBone Miner Res. 2004 Mar;19(3):429–35.

26. Vitamin D Metabolism and Treatment in Chronic Kid-ney Disease: Overview. Available from URL:http://www.medscape.org/viewarticle/571558.[ac-cessed on 2015 Aug 3].

34

IntroductionC-reactive Protein is an acute phase proteinpresent in the blood of acutely ill patients. Itconsists of five identical nonglycosylatedpolypeptide subunits noncovalently bound toform a disk shaped cyclic polymer with amolecular weight of about 115 KDa(1). This alphaglobulin is synthesized in the liver under thecontrol of interleukin-6. Formation of fatty steakon endothelial cells on any grade of infectioncause recruitment of leukocytes triggered byinflammatory cytokines such as interleukin-1 andtumor necrosis factor-alpha. The primaryproinflammatory cytokines such as CD-40influence the expression of messenger cytokinessuch as interleukin-6 which travel from local sitesof inflammation to the liver where a change inthe programme of protein synthesis of the acutephase response occur(3,7).

This acute phase protein binds with the cell wallC-polysaccharide of Streptococcus Pneumonaeand agglutinate the organism and so named asC-reactive Protein (CRP). CRP acts as nonspecific host defense especially against infectionand inflammation(2). Elevated value of CRP isfound in wide range of acute or chronic illnesslike gram positive and gram negative infection ,trauma, rheumatoid arthritis, tuberculosis etc. Inacute stage of infection CRP level increases topeak within 48 hours as much as 1000 folds.Normally its level ranges from 0.068 to 8.2mg/L.Chronic inflammation is an important factor forthe development and progression ofatherosclerosis. Different studies have revealedthe fact that there is a strong positive associationof CRP with the risk of future coronary eventslike coronary artery disease , peripheral arterydisease and cerebrovascular disease(4,8,9). It

HIGH SENSITIVITY C-REACTIVE PROTEIN - A CARDIAC MARKER FOR THE SCREENING OF

DIABETES MELLITUS PATIENTS

Sankar Roy1, Avik Chakraborty2, N. Gan Chaudhuri3, Shib Shekhar Datta4

1Asso. Prof. Dept. of Biochemistry, Tripura Medical College & Dr. BRAM Teaching Hospital, Hapania, Agartala, Tripura

2Asso. Prof. Dept. of Medicine, 3Diabetologist4Asso. Prof. Dept. of Community Medicine

AbstractThe High sensitivity C-Reactive Protein (hs-CRP) has been assayed in the present study inTripura. Total 150 number of Diabetes Mellitus(DM) patients were in D.M. patients assayedwith 85 male and 65 female aged above 45 years. The study shows that 7.33 % of D.M.patients have cardiac involvement observed in ECG with a marginal high value of hs-CRP.It is also observed that cardiac involvement is higher with the period of DM and age. Thehigher value is independent of sex ( p value- male 0.0037, female 0.0074), serum lipidprofile and renal status. Male and female showed the similar result. Hypertension or anyother disease do not have any relation with this. These patients are at higher risk than thoseof normal hs-CRP. By screening the diabetic patients with moderately high levels of hs-CRPgroup can be isolated and proper treatment can reduce the mortality and morbidity.

Keywords : DM, hs-CRP, CHD

High Sensitivity C-Reactive Protien in DM with CHD 3535

requires the use of high sensitivity CRP. hs-CRPassay have detection limit less than 0.03mg/L.Association of cardiovascular discases with type-2 Diabetes Mellitus is an established fact andthey have 2-4 fold high risk for CHD. Thepresent study aimed at finding the relation of thehs-CRP with the type-2 Diabetes Mellitus inTripura state. Low grade chronic infection leadsto moderate rise in hs-CRP levels. Diabeticpatients are more susceptible in this regard.Atherogenesis has also got a positive correlationwith the chronic infection. Elevated levels of hs-CRP predict not only cardiovascular events butalso the onset of type-2 diabetes mellitus,probably because hs-CRP levels correlate withseveral components of metabolic syndromeincluding those not easily measured in clinicalpractice such as insulin sensitivity, endothelialdysfunction and hypofibrinolysis(3,10,11). In majorstudies from the United States and Europe, hs-CRP levels predicted subsequent risk better thanLDL-cholesterol levels(6,12). According to AdultTreatment Panel (ATP III), hs-CRP levels lessthan 1, lto3 and greater than 3 mg/L define aslow, moderate and high risk groups respectivelyfor future vascular events. Mortality rateincreases when hs-CRP levels is more than3mg/L. Therefore, hs-CRP could be a predictorof the risk factor of cardiovascular events in DM.

Materials and MethodsCRP has been measured with the detection levelof 3 mg/L which is not sensitive enough to detectlower level value for prediction of cardiovascularrisk. For this, high sensitive immunoturbidimetricmethod is used to detect the lower level near to0.3mg/L. It is based on the light scatteringproperties of the antigen-antibody complexformed by the covalently coupling latex particlesto a specific antibody and useful to detect verylow level of CRP.The present study was conducted with 150number of Diabetes Mellitus type-2 patients whohave been suffering for more than 10 years. Allof them were either under hypoglycemic drugs

or Insulin. Their ages were 45 years and above.Equal number of persons were selected for studyas control. Along with hs-CRP, lipid profile andSerum urea, Creatinine values were alsoestimated and the patients with their normalvalues were selected for the study. All of themwere apparently well and did not suffer fromarthritis or any other inflammatory disease andhypertension.

ResultIn this study serum of total 150 known diabeticpatients were assayed for hs-CRP byimmunoturbidometry method after observing allformalities. Equal number of normal personswere also taken for the estimation of hs-CRP.Estimation of Lipid profile, urea and creatininewere done for all the patients and the normalindividual . Among them 85 (56.67%) patientswere male and 65 (43.33%) were female. Theresult has been divided into three groups-onegroup having hs-CRP levels less than 1mg/L,other group having hs-CRP levels between 1.1-3mg/L and the group having CRP value3.1-10mg/L. In case of male patients,it showsthat hs-CRP value of 57 (67.06%) patients hadless than l mg/L, 23 patients (27.06%) had l.l-3mg/L and only 5 patients (5.88%) patients hadin the range of 3.1-10 mg/L. the mean value was1.25+1.27 and p-value was 0.0037 which isvery significant.In case of females 42 (64.62%) patients had<lmg/L, 19 (29.23%) patients had in the rangeof l-1.3mg/L and only 4 (6.15%) patientsbetween 3.1-10mg/L. the Mean value was1.29±1.30 and p-value was 0.0074 which wasagain very significent. The hs-CRP value of total66% of the patients had less than lmg/L, 28%had l-3mg/L and only 6% had 3.1-10 mg/L withthe mean value 1.29+1.30 and p-value 0.0001.it is highly significant (Table 1, 2).It also shows that hs-CRP does not have anyrelation with the sex of the patients. So far theage is concern, patients of 45-55 years of agegroup had no cardiac symptoms. All of those

patients above 65 years with cardiacinvolvement were suffering from D.M. for morethan 15 years. Total 7.33% of Diabetic patientswith high hs-CRP value showed cardiacinvolvement in ECG.

SummaryThe hs-CRP level of a person increases in allsorts of acute inflammatory and infectious caseswhich subsides when the acute phase is over.But persistent moderately higher level of hs-CRPis found to be a risk factor for coronary heartdisease. The present study in Tripura shows that7.33% of D.M. patients had a marginal highervalue of hs-CRP. The higher value isindependent of sex, serum lipid profile and renalstatus. Male (p value 0.0037) and female (pvalue 0.0074) showed the similar result.Duration of D.M. and age of the patients had apositive correlation. The patients of 56-65 yearsof age group had 3.45 % of cardiac involvementand the patients of D.M. with more than 15 yearsduration and above 65 years had higher cardiacinvolvement (44.44%). Hypertension or anycardiac disease do not have any relation with

this. These patients are at higher risk than thoseof normal hs-CRP. By screening the diabeticpatients with moderately higher levels of hs-CRPgroup can be isolated and proper managementcan reduce the mortality and morbidity.

ConclusionHigher value of hs-CRP in Diabetic Mellituspatients is a predictiry of Coronary ArterialDisease (CAD) is an established fact. From thisstudy in Tripura, it can be concluded that 7.33%of D.M. patients had a marginal higher value ofhs-CRP and longer the duration of DiabeticMellitus with the increased age (more than 65years), higher is the cardiac involvement(44.44%). There is no relation with the sex,serum lipid profile and renal status of the patientsin this regard. Therefore, hs-CRP can be amarker of CAD for the patients of DM. If the hs-CRP is evaluated for the patients of DM infrequent intervals and those patients with higherhs-CRP can be screened and effective measurescan be taken, mortality and morbidity due toCAD can be controlled.

Fig.1 : Co-relation of age (in years) and hs-CRP (in mg/L) among study subjects(R2=0.235) [N=150]


Table 2 : Gender distribution and hs-CRP level among study subjects and controls

Gender Total hs-CRP level in Diabetics hs-CRP [Mean±SD] p value[N=150]

<lmg/L 1-3mg/L 3.1- Diabetics Control 10mg/L [N=150] [N=150]

Male 85 57 23 5 1.25±1.27 0.87±0.24 0.0037(56.67) (67.06) (27.06) (5.88)

Female 65 42 19 4 1.33±1.34 0.91±0.29 0.0074(43.33) (64.62) (29.23) (6.15)

Total 150) 99 (66) 42 (28) 9(6) 1.29±1.30 0.89±0.26 0.0001(100

(Student's T-test for 2 independent means, one-sided p value, 95% confidence interval)

High Sensitivity C-Reactive Protien in DM with CHD 37

Table 1 : Age distribution of study subjects (diabetic non-cardiac and cardiac patients)and gender matched healthy controls

Known diabeticsAge (in years) Controls [N=150]

N (%) Non-cardiac Cardiac TotalN (%) N (%) N (%)

45-55 48 (32) 45 (100) - 45 (30)

56-65 67 (44.67) 84 (96.55) 3 (3.45) 87 (58)

66 and above 35 (23.33) 10 (55.56) 8 (44.44) 18(12)

Total 150 (100) 139 (92.67) 11 (7.33) 150 (100)

37


References1. David R Claus, Alexander P, Osmand and Henry

Gewurz, : Radioimmunoassay of human C-reactiveprotein and level in normal sera, J. Lab. Clin. Med.Vol 87, No. 1, Jan 1978: 120-128.

2. Dixon. J.S., et al. : C-reactive protein in the serialassessment of disease activity in rheumatoid arthritis.Scand J Rheum ,13: 39-44, 1984

3. Shine . B., de Beer, F.C. and Pepys, M.B. : Solid phaseradioimmunoassay for human C-reactive protein. JLab Clinica Chimica Acta 117: 13-23, 1981

4. Dowling. P and Cook. S. : Immune events indemyelinating disease in Wolfgang. E., Ellison. G.W.,Stevens. J. G. and Andrew. J.M. (eds) : MultipleSclerosis. Academic Press Inc., New York. 269-277,1972.

5. Kushner, I. : "C-reactive protein in rheumatology" ,Arthritis Rheum 34:1065-1068,1991

6. Boekholdt SM, Hack CE, Sandhu MS, et al : C-reactive protein levels and coronary artery diseaseincidence and mortality in apparently healthy menand women: The EPIC-Norfolk prospectivepopulation study 1993-2003. Atherosclerosis187:415,2006.

7. Schultz. D.R. and Arnold P. I. : "Properties of fouracute phase proteins : C-reactive protein, serumamyloid A protein, glycoprotein and fibrinogen".Seminars in Arthritis and Rheumatism 20: 129-147,1990.

8. "Clinical Guide to Laboratory Test". Edited by N.W.Tietz, 3rd Edition . W.B. Saunders Company,Philadelpha, Pa. 19106 (1995).

9. Ridker P.M., Buring J.E., Shih J., Matias M.,Hennekens C.H., : Prospective study of C-reactiveprotein and risk of Carioovascular events amongapparently healthy women, Circulation, 1998,98:731-733.

10. Soinio M., Marniemi J., Laakso M., et al. : HighSensitivity C-reactive protein and Coronary heartdisease mortality in patients with type-2 diabetes. A 7years follow-up study. Diabetes Care. 2006; 29:329-331.

11. Pradhan AD, Manson JE, Rifai N, et al : C-reactiveprotein, interleukin- 6,and risk of developing type-2diabetes mellitus. JAMA 286:327,2001.

12. Ridker PM : Clinical application of C-reactive proteinfor cardiovascular disease detection and prevention.Circulation 107 : 363.2003.

39

IntroductionMedical teaching necessitates that teachersaddress the students’ needs and understand thevariations in learners’ styles and approaches interms of being sensitive and supportive(1).Worldwide, the curriculum of medical educationnow emphasizes that knowledge should beutilized for the development of bettercommunication skills. This acts as a steppingstone towards the provision of quality care forthe patient(2,3). Most universities throughout theworld are seeking appropriate teaching methodsto enhance clinical decision making and providecontinuous, self-centered learning(4). There arevarious methods of teaching medical studentsviz: (1) Lectures are efficient ways of deliveringinformation. Good lectures can introduce newmaterial or concepts to students through text-,web-, or field-based activities. They are not aseffective when it comes to stimulating thinking,inspiring interest in a subject, teachingbehavioral skills or changing attitudes. (2) Smallgroups learning: this involves a variety ofdifferent tasks like role play, problem basedlearning, discussions, brainstorming sessions,debates, workshops and presentations. The mainadvantages of this method are that it encourages

active learning and helps developcommunication and teamwork skills. (3) E-LEARNING-computer based learning:Computer technologies, including the internet,can support a wide range of learning activitiesfrom the dissemination of lectures and materials,access to live or recorded presentations and real-time discussions. However, there are concernsthat computer-based learning can detract frombuilding team-based working skills, that on-linefacilitators are not able to respond as quickly oradequately to student needs and thatinstructional design may often be compromisedin order to use educational technology fortechnology’s sake. (4) Self instruction modules:These include reading, workbooks, videos orcomputer-based modules, designed to teach aparticular concept. It is an efficient and flexibleway to increase cognitive knowledge. However,self-instruction as a teaching methodology is lesseffective than other methods since modules mayvary widely in design and educationaleffectiveness. Among the most important issuesis choosing the best learning method for thetopic at hand.Role playing is an upcoming teaching approachin medical education which provides for a better

ROLEPLAY : A METHOD OF TEACHING BIOCHEMISTRY TO MEDICAL UNDER GRADUATES

Mohit Mehndiratta, Stuti Gupta, Dinesh PuriDepartment of Biochemistry, University College of Medical Sciences

Delhi 110095

AbstractImproving the performance and attitude of medical students is possible if a subject is taught in a livelyand interesting way. The academic schedule usually includes nearly three to four hours of lectures perweek wherein a large volume of theoretical information is imparted in a short time. The consequencesinclude a reduced attention span and a lack of interaction between the students and teachers. In orderto improve the quality of teaching and reduce the tedium associated with didactic lectures we havetried to inculcate roleplay as a teaching medium in the academic curriculum. Through this review, wewould like to emphasize the relevance of roleplay and how it is used as a teaching method.

Keywords : Biochemistry, Medical education, Teaching methods


understanding of the subject and in theacquisition and retention of knowledge aboutvarious medical subjects. Van Ments(5) (1989)defines roleplay as: "... one particular type ofsimulation that focuses attention on theinteraction of people with one another. Itemphasizes the functions performed by differentpeople under various circumstances. The idea ofrole-play, in its simplest form, is that of askingsomeone to imagine that they are eitherthemselves or another person in a particularsituation. They are then asked to behave exactlyas they feel that person would.” In thesubsequent section, we have highlighted how touse role play for teaching biochemistry toundergraduate medical students.

DiscussionTo understand the root cause of any disease, theknowledge of biochemistry plays a veryimportant role as it deals with the chemistry ofbiomolecules and the environment at a cellularlevel. Learning biochemistry can sometimesbecome very monotonous and uninterestingsince it does not involve any interaction withpatients and hospital postings. Therefore, ourdepartment of Biochemistry, UCMS & GTBHospital conducted a roleplay to develop interestand enthusiasm among students. Itdemonstrated the consequences of good andbad laboratory skills in a doctor(6). We also usedroleplay in our department for teachingbiochemistry during a lecture to explain themechanism of glycogen synthesis. It is commonknowledge that the biosynthesis of glycogenoccurs in the liver with the help of an enzymeglycogen synthase (α 1 – 4 glucosidic linkage)using a preexisting starting molecule i.e. aglycogen primer. The donor of glucosyl is uridinediphosphate glucose. When further molecules ofglucose are attached in 1 – 4 position till 11residues are added, the branching enzymetransfers a part of the chain (at least six glucoseresidues) to the neighboring chain to form a 1 – 6 glucosidic linkage establishing a branching

point. The branches grow by the further additionof 1 – 4 glucosyl residue and further branching.We explained this information via role play inour department during a lecture and the way itwas conducted has been described as below:

Roleplay on biosynthesis of glycogen : Twovoluntary participants were called from thestudents. One was asked to act as a molecule ofglycogenin (glycogen primer) and the other asglycogen synthase (enzyme catalyzing 1,4glycosidic linkage). The left arm of the student(glycogen primer) acted as the C4 position ofglucose residue. The student (glycogen synthase)brought another student from audience who wasasked to act as uridine disphosphate glucose(UDPGlc) and his right arm acted as the C1position of glucose of UDPGlc. The left hand ofthe student (glycogen primer) and the right handof the student (UDPGlc), were put together toform 1,4 glycosidic linkage of glycogenmolecule. Two chain of 11 students (glucosemolecules) were thus created by holding hands(1,4 glycosidic linkage). Another student wasasked to act like the branching enzyme andshifted 6 students from one chain to anotherchain forming 1,6 glycosidic bond. This is howstudents were explained the importance ofvarious enzyme and glycogen primer in thesynthesis of glycogen molecule. At the end of the lecture when enquiries weremade about whether the medical students foundrole play helpful. We found that performing roleplay in a lecture was a big success because of thefollowing reasons:1) The topic became interesting and playful andleft a lasting visual impression2) It helped to provide a better understanding ofthe topic at hand and hence increased retention. 3) This method provided an encouraging,motivational and student centered form oflearning.4) It helped students to discuss their doubts andit increased their confidence levels in the topicMaier (2002) suggested that role-play should be

Role play for Teaching UG Students 4141

selected as a method of teaching according towhether the educational goal addressesknowledge, attitudes or skill(7). There are a fewpoints that should be kept in mind whiledelivering a roleplay: 1) The aims and objectivesof the task and roles should be made clear to thestudents, 2) Roles should be able to depict thereal interaction between the biomolecules at acellular level which creates an attention-grabbingenvironment, 3) Roleplay should be able torelate to the context in which students arelearning, 4) Students should be able toacknowledge potential difficulties in the topicrelating to role-play, 5) The importance ofplaying all roles should be emphasized, 6) Thestudents should always be allowed to work withtheir friends, 7) It should be ensured thatcommunications should be enthusiastic andinteresting, 8) Opportunities should be providedfor debriefing, 9) The experience gained fromthe roleplay should be summarized, 10)Feedback should be taken from the studentsafter each role play.Hence, with the appraisal response from thestudents, one can give a serious thought to theuse of roleplay in the current teaching system ofmedical education. However, further research is

needed to investigate its effectiveness in theacquisition and retention of knowledge in 1styear MBBS students.

References

1. Shankar PR. Using case scenarios and role plays toexplore issues of human sexuality. Educ Health2008;20:108.

2. The Royal Australian College of General Practition-ers. Training program curriculum. 2nd edition. Mal-bourne; RACGP:1999.

3. Stewart MA. Effective physician-patient communica-tion and health outcomes: a review. Can Med Assoc J1995;152:1423-33.

4. Magnusen L, Ishida D, Itano J. The impact of the useof inquiry based learning as a teaching methodologyon the development of critic thinking. J Nurs Educ2000;8:160-7.

5. Van Ments M: The Effective Use of Role Play: A Hand-book for Teachers and Trainers Nichols Publishing;New York: 1989.

6. Mehndiratta M and Puri D. Adopting role play fortraining medical interns about sample collection andprocessing for laboratory investigations. Ind j of MedBiochem 2015;19(1).

7. Maier HW: Role playing: Structures and educationalobjectives. The International Child and Youth CareNetwork 2002 [http://www.cyc-net.org/cyc-online/cycol-0102-roleplay.html].

42

IntroductionDiabetic retinopathy (DR) is a vascular disorderaffecting the microvasculature of the retina. It is estimated that Diabetes Mellitus affects 4 percent of the world’s population, almost half ofwhom have some degree of DR at any giventime(1).Magnesium is a:

1. cofactor for enzymatic reactions thatrequire ATP

2. key component in various reactionsthat require kinases (300 enzymes).

3. critical element in cellularproliferation and apoptosis.

4. regulator of ion channels. Cellular Magnesium deficiency can alter theactivity of membrane bound sodium-potassiumATPase that is involved in the maintenance ofgradients of sodium, potassium and in glucosetransport(2).

AimTo determine serum magnesium concentrationin patients, with and without diabetic

retinopathy; and study any alteration orassociation, there of

Inclusion CriteriaPatients with Diabetes mellitus, diagnosedclinically (supported by earlier Blood Glucoseconcentration, HbA1c%, wherever available);attending the retina clinic in the Department ofOphthalmology, Assam Medical College. Directand indirect ophthalmoscopy and fundusfluorescein angiography, were used to diagnosediabetic retinopathy.

Exclusion CriteriaRefusal of consent,Retinopathy other thandiabetic retinopathy,Serum creatinine > 1.5mg/dl.Use of Diuretics, Hormonal preparations (otherthan insulin), Antacids, Anticonvulsants,Lithium, Cytotoxic drugs, Mineral and Vitaminsupplementation;Acute/chronic diarrhea ormalabsorption, Pregnancy, Lactation,Endocrinological dysfunction, critical illness orany incapacitating disorder of the locomotorsystem;History of alcohol consumption.

A PERSPECTIVE ON MAGNESIUM IN DIABETIC RETINOPATHY

P. Gupta, R. K. GoswamiDepartment of Biochemistry, AMCH, Dibrugarh, Assam

AbstractDiabetic retinopathy (DR) is a vascular disorder affecting the microvasculature of the retina. It hasbeen suggested that hypomagnesemia may induce altered cellular glucose transport, reducedpancreatic insulin secretion, defective post receptor insulin signaling, and/or altered insulin-insulinreceptor interactions. The study is aimed to determine the serum magnesium concentration in diabeticpatients, with and without diabetic retinopathy and study of any association thereof.In patients withno retinopathy, the mean serum magnesium concentration was found to be 2.52+0.15 mg/dl, and inthose with diabetic retinopathy the mean serum magnesium concentration was found to be 2.32+0.11mg/dl. The difference was found to be highly significant but no significant difference in the meanserum magnesium, when compared on basis of whether the patients were aged 50 years or less orabove 50 years and when compared on basis of sex. Low magnesium promotes endothelial celldysfunction, induces proinflammatory and pro-fibrogenic response, reduces protective enzymesagainst oxidative stress, and interferes with normal cell growth and regulation of apoptosis.

Keywords : DR, ATP, Hb A1C

Magnesium in Diabetic Retinopathy 4343

Materials and MethodsA total of 42 patients were studied. Out of the 42patients, 21 patients had diabetic retinopathywhile 21 did not have diabetic retinopathy. Theparameters studied were serum magnesium,blood glucose, blood urea, serum creatinine,urinary albumin. Analysis of serum magnesiumon the basis of age groups, sex, treatment beingreceived for diabetes was done.The analyses wassupported by graphical representations andvarious statistical findings carried out by meansof Microsoft Excel and SPSS 20.0

DiscussionThe patients with no diabetic retinopathy hadsignificantly higher levels of mean serummagnesium (2.52+0.15) mg/dl; while those withnon-proliferative diabetic retinopathy who had amean serum magnesium level (2.32+0.11)mg/dl. The finding is in agreement with studies in1978 by P. McNair et al(2); in 2004 by IshratKareem et al(3) and in 2011, Dayanand CD etal4. Irrespective of whether the patients were aged50 years or less or above 50 years, there was nosignificant difference in the mean serummagnesium in the two age groups havingretinopathy or not.The age of patients was not asignificant predictor of plasma Mg in a study ondiabetic patients conducted by Monika K. Wälti5in Switzerland in 2003. The mean serum magnesium showed nosignificant difference between males and femaleswith no retinopathy.The mean serummagnesium concentration also showed nosignificant difference between males and femaleswith retinopathy. Sex of patients was not also nota significant predictor of plasma Mg in a studyon diabetic patients conducted in Switzerland in2003.There was no significant difference in serummagnesium, when patients with diabetic

retinopathy were grouped, as to whether theywere receiving insulin or oral hypoglycemicagents. Muhammad Murtaza Kause et al6 hadshown similar findings in one of the very fewstudies done.

ConclusionLow magnesium has been suggested to :

1. promote endothelial cell dysfunctionand thrombogenesis via increasedplatelet aggregation and vascularcalcifications,

2. induce proinflammatory and pro-fibrogenic response,

3. reduce protective enzymes againstoxidative stress,

4. And even interfere with normal cellgrowth and regulation of apoptosis,due to magnesium’s role in DNAsynthesis and repair.

Urinary excretion of Mg, especially in patientswith unsatisfactory metabolic control which is ahallmark of patients with diabetic retinopathysuggests that lower magnesium concentrationcould, in fact, be an effect of the disease. Thus,measurement of serum magnesium andreplenishment in deficient states, by means oforal supplementation could be a possibledeterrent to the progression of diabeticretinopathy.Serum magnesium concentration, asan independent and sensitive marker of diabeticretinopathy , could not be established in ourstudy. Interpreting the role of serum magnesium , in thelight of other predictors of diabetic retinopathylike duration of diabetes mellitus, glycemic statusin more elaborate studies could go a long way inrejuvenating researchers interests towards serummagnesium’s oft ignored role in Diabetes and itscomplications.

Parameters Methods

Serum Magnesium Calmagite Method

Glucose Glucose Oxidase / Peroxidase(Fasting and Post Prandial)

Blood Urea Mod Berthelot Method

Serum Creatinine Alkaline Picrate Method

Urinary Albumin Reagent Dipsticks

Fig. 1 : Patient distribution according to Age Groups they belong to

Methods of Investigation of Biochemichal Parameters


Fig. 3 : Blood Glucose Concentration in Patients with and without Diabetic Retinopathy

Fig. 4 : Mean serum magnesium concentration in patients with and without diabeticRetinopathy

Fig. 2 : Patient Distribution on the basis of sex


Fig. 6 : Mean Serum Magnesium Concentration with regard to Sex

Fig. 5 : Mean Serum Magnesium Concentration with regard to Age Group

Fig. 7 : Mean Serum Magnesium Concentration with regard to Treatment being received for Diabetes Mellitus



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