Volume 9 Number 1 January-June 2021
INTERNATIONAL JOURNAL OF CONTEMPORARY MEDICINE
Editorial Team
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Prof. Daya Chand
Department of Paediatrics, Saraswati Institute of Medical Sciences
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1. Dr. Gajendra Kumar Gupta, Professor, Community
Medicine Department, Santosh Medical College
Ghaziabad (UP) - 201 009.
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Dermatology & Deputy Medical Superintendent,
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college & Hospital, Salem,- 636008, Tamil Nadu
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Rohtak
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PGIMS, Rohtak
5. Prof Geeta Deshmukh, Pathology, Sharda University ,
Greater Noida
6. Dr Ajay Deshmukh, Cardiology, Sharda University,
Greater Noida
7. Dr Deepika Agarwal, Associate Professor (Community
Medicine), School of Medical Sciences & Research,
Sharda University, Gr Noida
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 I

INTERNATIONAL JOURNAL OF
CONTEMPORARY MEDICINE

CONTENTS

Volume 9, Number 1 January-June 2021

1. Appraisal of Beneficiaries’ Perspective on Opportunities and Barriers of NCD Clinics in a Coastal

District of Kerala................................................................................................................................................ 1
Aranya GN, Athirarani MR, Sujitha Elavally, Sairu Philip

2. The Ability to Interact with Schizophrenic Patients through Socialization Group Activity Therapy .............. 6
Jek Amidos Pardede , Arya Ramadia

3. Effect of Core Stabilization Exercises on Balance Performance in Older Adults ........................................... 12

Ketki Ponde, Ronika Agrawal, Nazneen Khalil Chikte

4. Evaluation of Quality of Life in Diabetic Population with and without Diabetic Polyneuropathy.................. 18
Manoj Abraham M , Hari Hara Sudan S, Pavithra V

5. The Deadly Duo-A Combination of Allergy and Acute Coronary Syndrome A Case of Kounis
Syndrome Type 1.............................................................................................................................................. 24
Ramkumar Rajappan, Bivin Wilson, Priya Kubendiran, Rajpal K.Abhaichand, Abhishek Kasha

6. A Rare Case of Pneumonia and Haemoptysis Caused by Citrobactor Freundii in a Young

Immunocompetent Male .................................................................................................................................. 27
Sushil Upadhyay

7. Association of XmnI Polymorphism with Fetal Hemoglobin Level in Sudanese Patients with Sickle
Cell Disease...................................................................................................................................................... 31
Tarig Osman Khalafallah Ahmed, Abeer Alshazaly Abdulrahman Altag Ahmed Abdalla Agab Eldour,
Anass M. Abbas, Manar G.Shalabi, Asaad Ma.Babker

8. Association of Glycated Hemoglobin and Dyslipidemia Inpatients with Type 2 Diabetes Mellitus in a
K.M.C.H. Katihar, Bihar-A Retrospective, Cross-Sectional and Descriptive Study..........................................................35
Amresh Kumar, Jiut Ram Keshari, Manish Kumar, Manish Kumar
DOI Number: 10.37506/ijocm.v9i1.2924 International Journal of Contemporary Medicine- January-June 2021, Vol 9, No.1 1

Appraisal of Beneficiaries’ Perspective on Opportunities and

Barriers of NCD Clinics in a Coastal District of Kerala

Aranya GN1, Athirarani MR2, Sujitha Elavally3, Sairu Philip4

Lecturer, Govt. School of Nursing, Govt. Medical College, Kozhikode. Kerala, 2Associate Professor ( CAP)
1

Govt. College of Nursing, Govt. Medical College, Thiruvananthapuram. Kerala, 3Assistant Professor, Govt.
College of Nursing, Govt. Medical College, Thiruvananthapuram. Kerala, 4Vice Principal, Professor and Head of
Department, Dept. of Community Medicine, Govt. TD Medical College, Alappuzha, Kerala

Abstract
Background: Non-Communicable diseases (NCDs) have become the main causes of morbidity and
mortality in many developing countries. In India, NCD Clinics are set up by the guidelines of National
Programme for Control of Diabetes, Hypertension, Cardiovascular Disease and Stroke (NPCDCS) for the
control, prevention and treatment of NCDs.  Govt of Kerala introduced the NCD clinics to compact the
disease burden of the state in 2010 through the National Health Mission.

Objective: To appraise the beneficiaries’ perspective on opportunities and barriers of NCD Clinics in
Alappuzha district.

Methods:   It was a qualitative study conducted over a period of 6 weeks among the people in the age
group of 30 years and above residing in Ambalappuzha taluk. 28 in-depth interviews and 18 focus group
discussions were conducted and the reviews of records in the primary health centres using a questionnaire
were done. Thematic analysis of observations and percentage estimation of service indicators were done. 

Result: The study revealed a cluster of four themes such as awareness about the services, availability,
accessibility, acceptability of services and Satisfaction about the services. Although there is receptiveness
to the services, barriers to mainstreaming also exist which persuade them not to utilise these services. In all
PHCs the indicators for screening for NCDs are less than 80%. Screening services should be strengthened
more. So, the need to revamp the structure and systems to enhance the utilisation of the services of NCD
Clinics is highlighted. 

Keywords: NCD Clinics, Opportunities, Barriers, Kerala

Introduction clinics are conducted regularly in all PHCs in Kerala, the

Non-Communicable Diseases (NCDs) are an
increasing threat to public health posing heavy economic
burden for health systems1,2. Currently, NCDs account
for almost two-thirds of deaths globally and it is 61% of
all deaths in India .3, 4,5 WHO initiated many innovative
and action-oriented responses and Government of
Indiaintroduced a national program for controlling
Non-communicable diseases called National Program
for Prevention and Control of Cancer, Diabetes,
Cardiovascular Diseases and Stroke (NPCDCS) in
the second half of 2010. As per the programme, NCD
success of any programme depends on the acceptability
and satisfaction of the beneficiaries6. The present study
intends to appraise the beneficiaries’ perspectives on
opportunities and barriers of NCD clinics. 
Materials and Methods 
The study was conducted in Alappuzha district of
Kerala using a qualitative research design. The population
consisted of adults in the age group of ≥ 30 years residing
in the study area. They were grouped into four categories
such as Utilisers of NCD clinics with NCD, Utilisers
of NCD clinics without NCD, Non-utilisers of NCD
2 International Journal of Contemporary Medicine, January-June 2021, Vol.9, No. 1
clinics with NCD, Non-utilisers of NCD Clinics without
NCD. Persons without NCD were also included as they
are eligible for screening in the NCD clinics as per the
NPCDCS guidelines. Among the six taluks of Alappuzha
district, Ambalapuzha was selected randomly, out of the
16 Community Health Centres of Amabalapuzha taluk
two CHCs were selected one each from the urban and
rural area. The participants were chosen from all the ten
PHCs coming under both CHCs. The utilisers of NCD
clinics were approached either during their visit to the
NCD clinics or tracked from the community with the
help of NCD registers. The non-utiliser was selected
from the field area through home visits. The Frontline
health workers, ASHAs and JPHNs were utilised for
the identification of non-utilisers from the field. The
topic guides for Focus Group discussion (FGD) in-
depth interviews (IDI) were validated by experts and
the participants were purposively chosen. The selection
at this phase was purposive and the data were collected
through FGD and IDI. The guides of FGD and IDI were
validated by the subject experts before the administration
in the sample. Before data collection, the gatekeepers
were informed about the conduct of the study. A total
of 28 IDIs and 18 FGDs were conducted. The venue for
the conduct of FGD and IDI were selected as per the
preference of the participants. There was representation
from males and females from urban and rural areas. The
number of members in a group ranged from 6 to 12. The
homogeneity of the participants in all FGDs was ensured
for conducive group dynamics during the discussions.
Probing and prompting questions, counter questioning,
repetition, and summing up were used in the interviews
to ensure that the information obtained was credible.
A neutral attitude was maintained by the interviewer
throughout the interview. Nonverbal observations during
and immediately after the interviews were recorded as
field notes. The researcher maintained a reflective diary
throughout the study to note personal reflections, biases,
and assumptions. The Analysis was done by Colaizzi
7 step data analysis method, which involves acquiring
a sense of each transcript by reading and re-reading,
extracting significant statements, formulating meaning
from the statement, creating themes from the formulated
meaning, defining and describing the phenomenon
under study, identifying the fundamental structure and
validating the data with suitable stakeholders. 7 Semi-
quantitative analysis was done for the interpretation of
the viewpoints of participants (Table1).
Results
The findings from FGDs and IDIs and were
categorized as Opportunities and Barriers of NCD Clinics
under the themes such as awareness about the service,
availability and accessibility of services, Acceptability
of services and Satisfaction about the services.
I. Awareness about the services of NCD clinics 
Ia. Opportunities
A majority of utilizers (5+) and Non-Utilizers (4+)
were aware of the services of NCD Clinics. They were
informed about the clinics from health care professionals
and community leaders. Some described primarily
interpersonal information sources available to them
including knowledge acquired through experience and
from family, friends and colleagues.
“Once I had a bad headache and I fell and somebody
took me to the hospital. My BP was high and after getting
treatment from there, they informed me about the NCD
Clinics and now I am a regular user of this clinic” -
Utiliser of NCD Clinics (FGD1)
I b. Barriers 
During the interviews with participants, a few
participants (2+) from Non-utiliser category were found
unaware about the services of NCD Clinics. Some (2+)
of the non-utilisers reported needs for strategies like
availing the new technologies such as social media for
identifying the beneficiaries and reminding them about
next check-ups.
“No health visitor came to my home. Nobody
informed me about the NCD Clinics” - Non-Utiliser of
NCD Clinics ( IDI10).“I had heard about the clinics but
I was unaware that it provides screening services to all
above 30 years. I thought it is only for those who have
the disease” -Non-utiliser of NCD Clinics (FGD17)
II. Availability and Accessibility of services 
Availability and Accessibility of services is the major
element of the utilisation of services. The utilisation of
the services would be better if services and facilities are
easily available to the beneficiaries
 International Journal of Contemporary Medicine- January-June 2021, Vol 9, No.1
II a. Opportunities  go to any other place. We get all the things free of cost.
A majority of utilisers (4+) and some of the non-
utilisers (2+) reported that the screening activities and
registration are done in the subcentres. Almost all (5+)
utilisers and non-utilisers (5+) had an understanding
about the importance of screening all the people at the
age of 30 and above for Non-communicable diseases, to
detect it and to start treatment as early as possible.
“Screening for Non-communicable diseases is
essential. This helps to identify whether we have any
disease or not and helps to change our dietary pattern”
-Utiliser of NCD Clinics (IDI7).
II b. Barriers 
A few participants across the utiliser (2+) and non-
user (2+) category expressed their displeasure, because
of how the NCD Clinics are operated. They felt there
was long waiting in the outpatient department and the
subcentres did not open sometimes.
“The sub-centres will not be opened when we visit
there on the same day which is being fixed by the health
care people. It is one of the major faults from the side
of the health care personnel” -Utiliser of NCD Clinics
(FGD1)
III. Acceptability 
The acceptability of services is another reason
for utilising the services of NCD clinics. People’s
preferences for utilising or not utilising the services were
obtained to know about the opportunities and barriers.
III a. Opportunities   IV a. Opportunities
Almost all (5+) utilisers perceived the existing
services as acceptable and they are ready to continue the
services. Some opined that it is better to use government
facilities than private. Some of the non-utilisers (3+) say
that as it is free of cost and is nearby so it is better to use
the services than any other facilities.
“Most of the people coming here are poor and aged.
In my opinion, it is better for all to utilise the services as
it is the responsibility of the Government to take care of
the health of the people so we get good care from there”
-Utiliser of NCD Clinics with NCDs (IDI1). “We have
a very good health centre nearby then why should we
3
My family will come here only”-Non-Utiliser of NCD
Clinics without NCDs (IDI14)
III b. Barriers 
The preference of a particular doctor is an important
aspect. Some of the non-utilisers (2+) opined that they
prefer the same doctor to consult all the time they went
to the health centre, which may not be possible in the
NCD Clinics. Some had a preference to other systems
of medicine. Some (2+) from the non-utiliser category
are afraid about allergies to the Allopathic medicines
and some think that they get other diseases by taking
the medications. Some participants (2+) says that the
investigations were done in government institutions
sometimes shows false result so they are reluctant to
utilise NCD Clinics.
“It is a difficult thing that we cannot see the same
doctor when we come for next time so we have to explain
all the things again. We cannot explain all the things to
a new and unfamiliar doctor” -Utiliser of NCD Clinics
with NCDs (IDI2)
 IV. Satisfaction about the services. 
Satisfaction about the services available is one of the
major factors which prompt the people to utilise or not
to utilise it. It emphasizes patients’ expectations of care
and perceived quality of care. Different categories of
people opined differently in the satisfaction component.
These viewpoints lead to quantification the opportunities
and barriers as given below.
 
Most of the utilisers (5+) express their satisfaction
with the services of NCD clinics as it is easily available,
accessible, and affordable to them. Most of the Non-
Utilisers (4+) expressed that they will utilise the services
of NCD Clinics if they came across with any of the NCDs
in future. Some suggest that they will be more satisfied
if the old people get nutrition supplements through
subcentres. It is observed that most of the beneficiaries
were ready to pass information to the community if they
or their family members start experiencing the benefits
of NCD Clinics.
4 International Journal of Contemporary Medicine, January-June 2021, Vol.9, No. 1
“It’s a good service which is affordable to us and
we get it nearby. I am satisfied with the service. That’s
why I come again and again”-Utiliser of NCD Clinics
(IDI1)
IV b. Barriers  medications will not be there, so we have to go outside
There are few (2+) participants across the Non-
utilisers’ category, who expressed dissatisfaction
regarding the services in NCD Clinics. They felt that
Table 1: Qualifiers used for Semi quantitative Expression of Observations
Adjectives used Proportion of respondents
Very few <10%
Some 10-24%
Approximately half 25-49%
Majority or over half 50-74%
Most 75-89%
Almost all >90%
Discussion
Even though the people are aware of NCD clinics,
they are not taking initiative to visit the clinics until the
symptoms arise. There is need for additional efforts to
improve the reach of services especially the screening
services to the unreached. These findings are supported
by another study which shows a significant association
between health workers’ visit with the utilization of
the program. If initiations are taken for scaling up IEC
activities, it will improve the utilization. There is only
a small proportion percentage of people who are not
aware of the services of NCD clinics. These findings
differ from the finding of a similar study in Surender
Nagar district Gujrat which reveals that the programme
is new and hence awareness about this programme per
se was low. Hence it would be worthwhile to conduct
regular sensitization activities for the public so that
they come back for follow up and utilize the services
adequately [8]. The findings of the study have a lot of
implications in the field of community health, research
medicines are not available, there is a long waiting period
in the outpatients’ department and the surroundings of
clinics are not cleaned.
“We will get medicines but the most important
for that. It will be costly too” -Non-Utiliser of NCD
Clinics with NCDs (IDI18)
Qualifier used
<1+
1+
2+
3+
4+
5+
and administration. When the opportunities and barriers
of NCD clinics are identified, necessary steps can be
taken to combat the barriers through better planning of
educational programmes and other interventions.
Conclusion
The study was intended to appraise the beneficiaries’
perspective on opportunities and barriers of NCD clinics
in Alappuzha district. The results of the study show that
the NCD clinics in Sub centre, PHCs and CHCS help to
deal with the prevailing NCD burden of the state more
effectively. There is awareness about the services of
NCD Clinics and the services are well perceived by them.
Although there is receptiveness to the services, barriers
to mainstreaming also remain which persuade them not
to utilise these services. There is need for individual
level of awareness regarding the screening and treatment
services available which can be regularly given through
community level volunteers and frontline health workers.
Regular supply of medicines, maintaining standard of
 International Journal of Contemporary Medicine- January-June 2021, Vol 9, No.1
care, prompt and quality services, counselling regarding
lifestyles and fear of adverse reactions of long-term
medication can further improve the acceptability and
satisfaction of services.
Ethical Considerations: The permission for the
conduct of the study was obtained from the Institutional
Ethics Committee and written informed consent were
obtained from the participants.
Financial support and sponsorship: NIL
Conflicts of Interest: There are no conflicts of
interest.
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Colaizzi’s descriptive phenomenological method.
The Psychologist, 28(8), 643-644.
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6 International Journal of Contemporary Medicine, January-June 2021, Vol.9, No. 1 DOI Number: 10.37506/ijocm.v9i1.2925

The Ability to Interact with Schizophrenic Patients through

Socialization Group Activity Therapy

Jek Amidos Pardede1, Arya Ramadia2

1
Nursing Study Program, Sari MutiaraIndoensia University, North Sumtra Indonesia,
2
Nursing Study Program, STIKes Al Insyirah Pekanbaru, Riau, Indonesia

Abstract
Social isolation is a disorder of interpersonal relationships that occurs due to an inflexible personality, which
causes maladaptive behavior and interferes with one’s function in relationships. One of the nursing actions
for schizophrenic patients with social isolation is Socialization Group Activity Therapy. Socialization Group
Activity Therapy is an effort to facilitate socialization skills in schizophrenia patients with social relationship
problems. The purpose of this study was to determine the effect of socialization group activity therapy on
the ability to interact with schizophrenic clients. The research design used one group pre-post test design,
the sampling technique used was purposive sampling and the total sample was 21 respondents. The ability
to interact socially was measured using a questionnaire sheet before and after therapy using a paired sample
test. The analysis showed that there was a significant effect with p = 0.014 (p <0.05). The conclusion is that
Socialization Group Activity Therapy is one of the effective therapies to improve the interaction ability of
schizophrenic patients.

Keywords: Socialization Group Activity Therapy, Social Interaction, Schizophrenia.

Introduction severe mental disorder that affects as many as 1 in 100

Schizophrenia is a group of psychotic reactions that
affect various areas of individual functioning, including
thinking, communicating, accepting, interpreting reality,
feeling, and showing emotions because schizophrenia
is a chronic, severe, and disabling disease, a brain
disorder characterized by chaotic thoughts, delusions,
hallucinations, and strange behavior1,2. Negative
symptoms include difficulty starting a conversation, a
dull or flat effect, reduced motivation, reduced attention,
passivity, apathy, and social withdrawal and discomfort3.
According to4.Negative symptoms are responsible for
a significant proportion of the disability linked with
schizophrenia. They are more closely related to prognosis
than positive symptoms. Interest in negative symptoms
of patients with schizophrenia is now greater than
before, paralleling increasing attention to the functional
influence of negative symptoms5. Schizophrenia is a
Corresponding author:
Jek Amidos Pardede
jekpardedemi@rocketmail.com
people at some point in their lives6.
According to7that the behaviors that often appear
in schizophrenic clients are lack of motivation (81%),
social isolation (72%), poor eating and sleeping behavior
(72%), difficulty completing tasks (72%), difficulty
managing finances (72%), an appearance that is not neat
and clean (64%), forgetting to do something (64%),
lack of attention from others (56%), and not regularly
taking medication (40%). Social isolation refers to the
objective absence or paucity of contacts and interactions
between a person and a social network8.
Social isolation as a negative symptom in
schizophrenia is used by patients to avoid other people so
that unpleasant experiences in dealing with other people
do not happen again. Withdrawal is used by patients to
avoid other people so that unpleasant experiences in
dealing with other people do not happen again. Thus
social isolation is an individual’s failure to interact with
others as a result of unpleasant experiences as a threat
to the individual. Behaviors that are often displayed
by clients of social isolation are showing withdrawal,
 International Journal of Contemporary Medicine- January-June 2021, Vol 9, No.1
uncommunicative, trying to be alone, cool with their
thoughts and themselves, no eye contact, sadness,
dull affection, hostile behavior, expressing feelings
of loneliness or being rejected, difficulty building
relationships in their environment, avoiding other
people and express feelings of not being understood
by others9,10. Perceived social isolation, known more
colloquially as loneliness, was characterized in early
scientific investigations as “chronic distress without
redeeming features”. Recent research suggests that the
social pain of loneliness evolved as a signal that one’s
connections to others are weakening and to motivate
the repair and maintenance of the connections to others
that are needed for our health and well-being and for the
survival of our genes11,12.
Patients with problems lack social skills, cannot
communicate with others effectively, experience
difficulty in making friends, are able to solve problems,
find and keep jobs, which is the reason they isolate
themselves from society. Poor social skills are closely
related to recurrence of disease and patient return to the
hospital, this has been reported as an important factor
affecting prognosis13. A social skills training program
can help them return to society. This training has been
shown to be effective in increasing social adaptability,
reducing psychiatric symptoms, thereby reducing
rehospitalization rates, in addition to increasing patient
self-esteem14.
One therapy modality that can help build relationships
with other people is Group Activity Therapy, with
group activity therapy, patients are able to socialize,
know the context of reality, channel energy, increase
self-esteem. This is in accordance with the objectives
of Group Activity Therapy, namely to socialize and
increase reality testing, to increase awareness of the
relationship between emotional reactions and defensive
actions or behavior or channel emotions constructively
and improve cognitive and affective functions.
The results of the initial survey conducted at Mental
Hospital in Medan found that in 2020 as many as 13,065
people had schizophrenia. The results of interviews and
observations during Group Activity Therapy for up to
4 sessions with 9 schizophrenic patients. Schizophrenic
patients who attended Group Activity Therapy seemed
7
happy to participate in Group Activity Therapy and
were able to participate in these activities. During Group
Activity Therapy there is good cooperation between
patients. However, there were still 2 patients who gave a
passive attitude, seemed silent, and less happy with the
Group Activity Therapy activities. This shows that the
implementation of Group Activity Therapy is still not
optimal, making these patients less socializing with other
groups or patients and less interacting with other groups
and patients. This problem makes researchers interested
in examining whether there is an effect of therapy on the
patient’s ability to socialize properly when the patient
follows all the sessions given.
Research Methods
This study used a one-group pre-post test design
which aims to explain the effect of Socialization
Group Activity Therapy on the interaction ability of
schizophrenic clients. The population is the subject
of research. The population in this study were all
schizophrenia patients, amounting to 922 people.
The sample taken in this study were treated with
schizophrenic patients. The sampling technique
used purposive sampling, namely the technique of
determining the sample according to what is desired
so that the sample can represent the characteristics of
the population of 19 samples. The sampling technique
in this study was determined with a consideration of
criteria that focused on social isolation patients whose
criteria were as follows: Schizophrenic patients with
nursing problems social isolation, cooperative and able
to communicate, able to answer questions well, and
willing to participate in socialization group activity
therapy To complete all sessions, the researcher used
the Paired Sample Test statistical test to analyze the
difference in the average score of the ability to interact
with respondents before and after the intervention. The
significant test of the calculation results is to compare
the results of the calculation of significance (p) for
the “level of significance” ) = 5% (0.05) or 95% CI
(Confidence Interval). If the p-value <α (0.05) means
that the Socialization Group Activity Therapy has a
significant effect on the ability to interact with.
8 International Journal of Contemporary Medicine, January-June 2021, Vol.9, No. 1

Results
Table 1: Characteristics of Schizophrenic Patients With Social Isolation Problems

Characteristics n %

Age
· 20-29 years 3 14.3
· 30-40 years 14 66.7
· 41- 50 years 4 19.0

Gender
· Male 18 85.7
· Female 3 14.3

Education
· Junior High School 3 14.3
· Senior High School 18 85.7

Marital status
· Married 4 19.0
· Single 16 76.2
· Widower widow 1 4.8

In Table 1, it can be seen that the majority of respondents are 30-40 years old (66.7%), 18 people are male
(85.7%), 18 respondents have high school education background (85.7%), and most of the respondents are not
married (76.2%).
Table 2 Analysis of Changes in the Interaction Ability of Schizophrenic Patients Before and After Socialization Group Activity
Therapy

The ability to interact with

Mean n St. Deviation Std. Error mean
schizophrenic patients

The ability to interact with

schizophrenic patients before 2.00 21 .775 0.169
socialization group activity therapy

The ability to interact with

schizophrenic patients after 2.48 21 .512 0.112
socialization group activity therapy

In Table 2, it can be seen that there is a change in the
ability to interact with schizophrenic clients before and
after being given socialization group activity therapy,
with an average change in the ability to interact with
schizophrenic clients before socialization group activity
therapy (Mean = 2.00 and SD = .775), and the average
changes in the ability to interact with schizophrenic
clients after socialization group activity therapy (Mean
= 2.48 and SD. 512).
 International Journal of Contemporary Medicine- January-June 2021, Vol 9, No.1 9

Table 3: Effectiveness of Socialization Group Activity Therapy on Interaction Ability of Schizophrenic Patients

95% CI
The ability to interact
with schizophrenic Mean St.deviation SE T Df P
patients Lower Upper

The ability to interact

with schizophrenic
patients before and
-476 .814 .178 -.847 -.106 -2.682 20 0.014
after being given
social group activity
therapy

In Table 3, it can be seen that there is a significant difference between the ability to interact with respondents
before being given social group activity therapy and the ability to interact after being given social group activity
therapy from the Paired Sample Test results found p = 0.014 (p <0.05).

Discussion isolation, differences, and increase clients to participate

Changes in the ability to interact before and after
the intervention
The results showed that the mean interaction ability
of the respondent who had schizophrenia before the
intervention was mean = 2.00 and SD = 0.77. Meanwhile,
the ability of respondents with schizophrenia increased in
socializing after attending group activity therapy (mean
= 2.48; SD = 0.51). These results indicate that there is a
change in the ability to interact with respondents before
and after the intervention.
Socialization group activity therapy is an effort to
facilitate the socialization skills of a number of clients
with social relationship problems, which aims to improve
social relations in the group gradually, where patients
can introduce themselves, are able to get acquainted
with group members, are able to converse with group
members, are able to convey and discuss conversational
topics and be able to convey and discuss personal
problems to others15.
The assumption of the researcher, this ability is due
to the continuous process of implementing Socialization
Group Activity Therapy. In the group, there is a dynamic
of interacting and influencing each other so that other
respondents are stimulated to carry out what was taught
and what other respondents have succeeded in doing.
This is in accordance with the theory that the advantage
of group therapy is that it can reduce feelings of
and exchange ideas and problems with other people or
groups. In addition, it also provides opportunities for
patients to be able to receive feedback from others and
to learn various ways to solve other people’s problems.
Socialization Group Activity Therapy on Interaction
Ability of Schizophrenic Clients
Based on the results of research on the effect
of Socialization Group Activity Therapy on the
socialization skills of respondents assessed using the
Paired Sample Test statistical test, the calculated value
of p = 0.014 (p <0.05). The results of this study indicate
that there is an effect of Socialization Group Activity
Therapy on the socialization ability of respondents
before and after the intervention. The results of this
study indicate that respondents experienced problems
in interacting with other people before being given the
intervention. This is due to the absence of action or
stimulus that can change maladaptive behavior patterns
and a less therapeutic environment such as too many
patients in the treatment room and the patient’s lack of
ability to interact with other clients. In general, social
isolation patients feel good about their world and alone.
According to16, Humans are social beings who cannot be
separated from a condition called interaction and always
have mutual relations and influence with other humans
in order to meet their needs and sustain their lives.
The results of this study are consistent with the
research of17which shows that there is a significant
10 International Journal of Contemporary Medicine, January-June 2021, Vol.9, No. 1
effect of socialization group activity therapy on social
interaction skills (p = 0.00; p <0.05). Socialization group
activity therapy is one of the nursing interventions for
patients with social isolation nursing problems. Through
the process of socialization group activity therapy,
patients are trained to interact socially by getting to
know other people, chatting, expressing their feelings to
others. In the group, there is a dynamic of interacting
and influencing each other so that other respondents
are stimulated to carry out what was taught and what
other respondents have succeeded in doing. This is
in accordance with the theory that the advantage of
group therapy is that it can reduce feelings of isolation,
differences, and increase clients to participate and
exchange ideas and problems with others. In addition,
it also provides opportunities for clients to be able to
receive feedback from others and to learn various ways
of solving problems and can help solve other people’s
problems18.
The effect resulting from the activity of
socialization group activity therapy on the improvement
of the respondent’s socialization skills is because the
socialization group activity therapy is an effort to
facilitate the socialization skills of a number of clients
with social relationship problems. Schizophrenic patients
experience disturbances in daily functions, both in work,
social relationships, and self-care habits. However,
intensive handling, in the form of providing various
exercises or therapies, such as occupational therapy,
social skills training, and so on for schizophrenics, has
been shown to improve social skills and suppress their
social disability.Patients with problems lacking social
skills, unable to communicate with others effectively,
not making friends easily, or effectively solving their
problems, difficulty finding and keeping jobs, will further
isolate themselves from society. Poor social skills are
closely related to recurrence of disease and client return to
the hospital, these have been reported as important factors
influencing prognosis. A program of training social skills
for patients with social isolation problems and ultimately
successfully helping them return to society.
The assumption of researchers that the patient’s
ability is due to the process of implementing continuous
socialization group activity therapy. In the group, there
is a dynamic of interacting and influencing each other so
that other respondents are stimulated to carry out what
was taught and what other respondents have succeeded in
doing. This is consistent with the theory that the advantage
of group therapy is that it can reduce feelings of isolation
and increase patients to participation and exchange of
thoughts and problems with others. In addition, it also
provides opportunities for patients to be able to receive
feedback from others and can learn various ways of
solving problems, and can help solve other people’s
problems. It can be argued that in dealing with the fear
and insecurity of people with schizophrenia, a therapeutic
condition is needed which supports an orientation to reality
or reality and which encourages their interest in relating to
other people. Group intervention supports the members’
social relationships with each other, which is supported by
a therapist who can provide their socialization experience.
Conclusion
Mean interaction ability of schizophrenic patients
before socialization group activity therapy (Mean =
2.00, SD = .775). The average interaction ability of
schizophrenic patients after socialization group activity
therapy (Mean = 2.48, SD = .512) and the Paired Sample
Test results showed that there was a significant effect
on the ability to interact with schizophrenia patients
before and after being given socialization group activity
therapy, the p-value was obtained. = 0.014 (p <0.05).
Ethical Clearance- Taken from ethical committee
of institute: Sari Mutiara Indonesia University
Source of Funding- Self.
Conflict of Interest- Nil.
References
1. Rhoads J. Clinical consult for psychiatric mental
health care. Springer Publishing Company; 2010
Oct 25.
2. Pardede JA, Hamid AY, Putri YS. Application
of Social Skill Training using Hildegard Peplau
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the Capability of Social Isolation Patients.
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3. Videbeck, S, L,. Psychiatric Mental Heath Nursing.
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4. Vrbova K, Prasko J, Holubova M, Slepecky M,
Ociskova M. Positive and negative symptoms in
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schizophrenia and their relation to depression,
anxiety, hope, self-stigma and personality traits–a
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2018 Jan 1;39(1):9-18.
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Takeuchi H, Lee J, Hahn M. Treating negative
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6. Crawford MJ, Killaspy H, Barnes TR, Barrett B,
Byford S, Clayton K, Dinsmore J, Floyd S, Hoadley
A, Johnson T, Kalaitzaki E. Group art therapy as an
adjunctive treatment for people with schizophrenia:
multicentre pragmatic randomised trial. Bmj. 2012
Feb 28;344.
7. Stuart GW, Laraia MT. Principles and Practice of
Psychiatric Nursing. 8th ed. Philadelphia: Mosby.
2005:15-49.
8. Gardiner C, Geldenhuys G, Gott M. Interventions
to reduce social isolation and loneliness among
older people: an integrative review. Health & social
care in the community. 2018 Mar;26(2):147-57.
9. Herdman TH, editor. Nursing Diagnoses 2012-
2014: Definitions and Classification. John Wiley &
Sons; 2012.
10. Pardede JA. The Implementation of Family Tasks
with The Frequency of Recurrence of Social
Isolation Patients. Mental Health. 2017;4(2).
11. Cacioppo JT, Patrick W. Loneliness: Human nature
and the need for social connection. WW Norton &
Company; 2008 Aug 17.
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12. Cacioppo JT, Hawkley LC, Norman GJ, Berntson
GG. Social isolation. Annals of the New York
Academy of Sciences. 2011 Aug;1231(1):17.
13. Seo JM, Ahn S, Byun EK, Kim CK. Social skills
training as nursing intervention to improve the
social skills and self-esteem of inpatients with
chronic schizophrenia. Archives of psychiatric
nursing. 2007 Dec 1;21(6):317-26.
14. Heinssen RK, Liberman RP, Kopelowicz A.
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lessons from the laboratory. Schizophrenia bulletin.
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15. Keliat BA &Akemat. Model praktikkeperawatanpr
of esionaljiwa. Jakarta: EGC. 2012.
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TerapiKognitif Terhadap Kemampuan Interaksi
PasienSkizofrenia DenganIsolasiSosial.
JurnalIlmu Keperawat andan Kebidanan. 2020 Jul
25;11(2):226-35.
17. Hasriana, H., Nur, M., &Anggraini, S. The effect
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12 International Journal of Contemporary Medicine, January-June 2021, Vol.9, No. 1 DOI Number: 10.37506/ijocm.v9i1.2926

Effect of Core Stabilization Exercises on Balance Performance

in Older Adults

Ketki Ponde1, Ronika Agrawal2, Nazneen Khalil Chikte3

Associate Professor, M.A.Rangoonwala College of Physiotherapy and Research, Pune, 2Principal and Professor,
1

M.A.Rangoonwala College of Physiotherapy and Research, Pune, 3Intern, M.A.Rangoonwala College of

Physiotherapy and Research, Pune

Abstract
Objective: Fall is defined as unintentional loss of balance that leads to failure of postural stability. Around
30% of older adults aged over 65 years have an episode of falls each year.. All postural control components
undergo changes with ageing. Any impairment in neuromuscular, central nervous system and sensory
system leads to fall. So the aim of present study was to determine the effects of Core stabilization exercises
on balance performance in older adults. Methodology: Sixty participants both males and females aged
between 65 -75 years were divided into 2 groups, Experimental and Control group (n=30). Experimental
group performed core stabilization exercises 5 times a week for 6 weeks, while control group carried on
their routine daily activity for 6 weeks. Berg Balance Scale (BBS), Y-Balance Test, Functional Reach Test
were assessed at the baseline and after 6 weeks of intervention. Results: Statistical analysis revealed that
Experimental group showed significant improvement in BBS, Y – Balance Test and Functional Reach Test
scores with (p ˂ 0.05) post 6 weeks of intervention. Control group showed no significant improvement in
the scores. Conclusion: Core stabilization exercises had significant improvement on balance variables in
experimental group when compared to control group.

Key words: Core, balance, older adults, fall, trunk muscles.

Introduction movement and gait disorders leading to falls. [3]Muscle

Individuals above 65 years of age are considered to
be older adults. Around 30% of older adults population
aged over 65 years have an episode of falls each year.
[1]
. As the age advances there are physiological changes
which lead to lack of proprioception, reduced muscle
strength , decline in reflex reaction to sudden changes,
reduced sense of equilibrium , vision and decreased
cognitive ability.[2][3] Ageing is associated with decline
in balance ability and muscle strength which causes
strength is lost in the axial muscles i.e. core muscles
along with distal muscles which make it difficult to
maintain balance. [4]
Balance is the ability to maintain the body’s center
of gravity within the limits of stability as determined by
the base of support. [5]The ability to maintain balance
is an integrated task of neuromuscular, central nervous
system and sensory system. [1] As the age advances,
changes taking place in these systems leads to fall in
older adults people.

In static and dynamic situations, balance is achieved

Corresponding Author:
Dr. Ketki Ponde (PT),
Associate Professor, M.A.Rangoonwala College of
Physiotherapy and Research, Pune.
Address : 2390, K.B Hidayatullah road, Azam Campus,
Pune -411001. Contact no: (020)26437879
E -mail id: drketki85@gmail.com
by positioning body’s Centre of Gravity (COG) over the
Base of Support (BOS). [1] Dynamic balance activities
are the activities that cause the COG to move in response
to muscle activity. [5]Dynamic control is essential
in many functional tasks and involves integration
of proprioception, range of motion and strength. [5]
 International Journal of Contemporary Medicine- January-June 2021, Vol 9, No.1 13

Trunk extensors, flexors, and lateral flexors provide muscle quality, mobility and poor balance in older adults
spinal stability during every dynamic movement [6] .[7] So the study aims to measure effect of corestabilization
Impairments in trunk muscle such as decreased trunk exercises on balance in older adults.
strength or endurance, are likely to cause changes in
balance and mobility status which leads to fall in older Methodology
adults [7] Corestability is maintained by increasing the The study was commenced after approval
activity of coresegmental muscles. [8] from Institutional ethics committee. Sixty geriatric
participants both males and females aged 65-75 years
Core muscles are the kinetic link that transfers
whose Berg Balance Score was more than 40 and were
the torques and angular momenta between upper and
functionally independent were included in the study.
lower extremities during the execution of whole-body
Participants were excluded if they had history of recent
movements[9]Global muscles( Rectus abdominis, external
fractures of lower limb, spinal fractures in past 1 year
obliques and some parts of the erector spinae ) are ideal
and any cardiovascular and neurological impairment
for creating movement of the trunk and producing torque,
since past one year. Informed written consent from
because of their large moment arms and long levers as
all the participants were taken after the explanation
they are attached from the thorax to the pelvis.[6]These
of the testing procedure, protocol and duration of the
muscles are labelled as the prime movers for trunk or
intervention. Participants were allocated into two groups
hip flexion , extension and rotation. During whole body
i.e. Group (A) Experimental and Group (B) Control
movement stability of corespine is associated with
group. Group A was given core stabilization exercises
Local muscles.[5]Local muscles(Transversus abdominis,
like: Drawing in manuvers, Bent leg fall out, Drawing
multifidus, pelvic floor, diaphragm and internal obliques
in manuvers along with a) Lift bent leg to 90degree hip
) are responsible for producing sufficient force for
flexion b) slide heel to extend knee c) straight leg raise
segmental stability of the spine.[5] The co-ordinated
to 45 degrees were given which help them to activate the
muscle recruitment between the global muscles and
deep segmental muscles along with their normal daily
the local muscles during functional activities maintains
activities for 5 days week for 6 weeks, while Group B was
stability of the corespine.[8]Corestabilization exercises
not given any intervention and was told to carry out their
helps in improving neuromuscular control , strength
regular routine for 6 weeks. All necessary precautions
and endurance of the muscles [10].Corestability training
were taken in order to prevent any kind of fall during the
targets the muscles deep within the trunk which are
testing procedure and intervention. The measurement of
connected to the spine, pelvis and shoulders and it assists
variables Berg Balance Scale, Functional Reach test and
in maintaining good posture and provides the foundation
Y- Balance Test were taken pre training (o week) and
for arm and leg movements. [7]Exercises that target core
post training (post training)
muscles are effective for corestabilization and motor
control training and thus are used for maintaining
Statistical Analysis
balance. [3,11]
Statistical analysis was done in statistical package
Studies suggested that core muscles play an for social sciences .Paired t- test was done for Intra
important role in improving balance and training group while un -paired t- test was done for Inter group
functional mobility in older adults individuals. [12] A comparison.
study done by Suri et al., 2009 have shown associations
between diminished trunk muscle strength, endurance,
14 International Journal of Contemporary Medicine, January-June 2021, Vol.9, No. 1

Results
TABLE 1: Intra group comparison of Mean pre and post 6 weeks of intervention using paired t-test in Experimental Group.

  VARIABLES MEAN VALUE

P VALUE t VALUE
POST 6
    PRE
WEEKS

1 Berg Balance Scale 45.76 48.1 7.96E-17 -16.85

2 Y BALANCE TEST      

ANTERIOR 57.2 60.4 6.01E-08 -6.95

RIGHT POSTEROMEDIAL 45.3 48.6 3.29 E-08 -7.18

POSTEROLATERAL 34.16 37.2 4.81E-08 -7.03

ANTERIOR 57.13 60.26 6.31E-08 -6.93

LEFT POSTEROMEDIAL 44.13 47.06 3.47E-08 -7.16

POSTEROLATERAL 33.5 36 4.27E-09 -7.9

3 Functional Reach Test 18.16 20.8 1.14E-11 -10.4

Interpretation: Post 6 weeks of exercises there was significant improvement seen in scores of Berg Balance scale
(p≤ 0.05), Y balance test (p≤ 0.05) and Functional reach test (p≤ 0.05)
TABLE 2: Intra group comparison of Mean pre and post 6 weeks of intervention using paired t-test in Control Group

CONTROL GROUP

  VARIABLES MEAN VALUE

P INTERPRETATION OF
t VALUE
POST 6 VALUE SIGNIFICANCE
    PRE
WEEKS

1 BERG BALANCE SCALE 45.6 45.33 0.13 1.13 INSIGNIFICANT

2 Y BALANCE TEST    

ANTERIOR 55 54.6 0.14 1.09 INSIGNIFICANT

RIGHT POSTEROMEDIAL 43.2 43.4 0.27 -0.61 INSIGNIFICANT

POSTEROLATERAL 33.4 33 0.13 1.13 INSIGNIFICANT

ANTERIOR 57.2 57.3 0.38 -0.29 INSIGNIFICANT

LEFT POSTEROMEDIAL 42.5 42.8 0.28 -0.58 INSIGNIFICANT

POSTEROLATERAL 33 32.6 0.13 1.12 INSIGNIFICANT

FUNCTIONAL REACH
3 17.73 17.43 0.08 1.42 INSIGNIFICANT
TEST
 International Journal of Contemporary Medicine- January-June 2021, Vol 9, No.1 15

Interpretation: Post 6 weeks intervention there was no significant improvement seen in the control group scores
(p≥ 0.05)

TABLE 3: Inter Group Comparison of Mean of Variables using Un- Paired t-test between Experimental
and Control group

INTER GROUP MEAN DIFFERENCE

EXPERI-
  VARIABLES CONTROL P VALUE t VALUE  
MENTAL

BERG BALANCE
1 2.33 -0.33 3.2 E-10 8.23 SIGNIFICANT
SCALE

2 Y BALANCE TEST

ANTERIOR 3.26 -0.4 8.48E-08 6.17 SIGNIFICANT

RIGHT POSTEROMEDIAL 3.26 0.23 3.65E-08 5.13 SIGNIFICANT

POSTEROLATERAL 3.1 -0.46 1.87E-07 5.91 SIGNIFICANT

ANTERIOR 3.13 0.1 1.86E-06 5.34 SIGNIFICANT

LEFT POSTEROMEDIAL 2.93 0.26 6.07E-05 4.33 SIGNIFICANT

POSTEROLATERAL 2.5 -0.33 1.58E-08 6.56 SIGNIFICANT

FUNCTIONAL
3 2.63 -0.3 2.10E-12 8.95 SIGNIFICANT
REACH TEST

Interpretation: Significant improvement was seen in experimental group compared to control group (p≤0.05)

Discussion rapid and powerful torques. The local muscles consist

Core stabilization exercises were carried on
experimental group for 6 weeks. The exercises showed
significant improvement in balance as compared to
control group. Improvement in balance could be due to
core stabilization exercises that target the deep stabilizers
of the spine which play a crucial role in providing a stable
foundation upon which the limb muscles can move. [13]
The core stability system is the product of motor
control and muscular capacity of lumbopelvic-Hip
complex. It acts like a corset which gives tension to
the trunk muscles when activated. These muscles are
divided as local and global muscles. Global muscles
like Erector spinae, rectus abdominis, external oblique
and quadrates lumboram provides trunk motion with
of transverse abdominis, multifidus, internal oblique are
situated deep which provide dynamic segmental spinal
stability [15].
Statistical analysis showed significant improvement
in BBS score, Y balance test and Functional reach test
post six weeks of intervention. This could be attributed
due to TrA activation prior to and during lower limb
activity which helps in reducing the perturbing forces
on posture and balance [16]. Also the core stabilization
exercises provide protection to the low back muscles
that challenges the balance, flexibility and co ordination
[17].
The exercises enabled improvement of reaction
time which is important factor in optimal balance. The
repetitive exercises and weekly progression helped in
improving the endurance which was associated with
16 International Journal of Contemporary Medicine, January-June 2021, Vol.9, No. 1
balance performance. Rosa Cabanas et al suggested the
positive association of central nervous system (CNS)
stabilizing the spine through the contraction of trunk
and pelvis muscle in response to reactive forces of lower
limb. Panjabi also stated that contraction of core muscle
activates the postural responses by CNS which help in
controlling the balance.
Core stability exercises are effective in motor
control training. The exercise recover the postural
control function of body and increases the range of
motion. So it can be considered as appropriate exercise
for older adults.Motor learing which occurs during the
core training improves muscle reflexes and accelerates
proprioception which affects balance control.
Control group did not show any significant
change in Berg Balance Scale, Y – balance Test
(anterior,posteromedial, posterolateral) and Functional
Reach Test. As Ageing is an on-going process, there are
normal age associated changes taking place in the body
which leads to impairments in balance [1].Also, there is
decline of physiological capacities and deterioration of
ability to respond to stress in this period which increases
vulnerability of the older adults to various impairments
due to ageing process [4]. So there was no change seen in
the control group.
Conclusion
Based on the findings from our study, we conclude
that along with peripheral muscles strengthening
exercises, core stabilisation exercises are also important
in maintaining the balance in older adults.
Acknowledgement: we would like to acknowledge
the Old Age Homes in Pune and the participants for
giving their valuable time and allowing us to assess
them.
Source of Funding: NIL
Conflict of Interest: None
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18 International Journal of Contemporary Medicine, January-June 2021, Vol.9, No. 1 DOI Number: 10.37506/ijocm.v9i1.2927

Evaluation of Quality of Life in Diabetic Population with and

without Diabetic Polyneuropathy

Manoj Abraham M 1, Hari Hara Sudan S2, Pavithra V3

1
Principal, KG College of Physiotherapy (Affiliated to The TN Dr MGR Medical University), KG Hospital &
PG Medical Institute, Coimbatore. Tamil Nadu, India, 2Associate Professor, 3Assistant Professor, KG College
of Physiotherapy (Affiliated to The TN Dr MGR Medical University), KG Hospital & PG Medical Institute,
Coimbatore. Tamil Nadu, India

Abstract
Background: Diabetes is a chronic, metabolic disease characterized by elevated levels of blood glucose, which
leads over time to serious damage to the heart, blood vessels, eyes, kidneys and nerves. The complications
of the Diabetes such as Diabetic Poly Neuropathy impacts the patient’s Quality of Life, later may result in
early death.

Methods: A total of 260 samples were taken and divided into 3 groups, Diabetes with DPN (G1), Isolated
DM (G2), and Controls (G3) with 65, 65 and 130 samples respectively. They were assessed for Quality
of Life with WHOQOL-BREF Questionnaire. Data were collected and taken for analysis. The overall
WHOQOL-BREF scores of the three groups were 83.86 ±5.93, 92 ±6.75 and 98.33 ±0.94 respectively.
There was a significant statistical difference in WHOQOL-BREF in G1, G2 and G3 (p=0.000), but there
was no significant statistical difference in WHOQOL-BREF in between G2 and G3 (p=0.847) in domain 2.

Conclusion: The findings in this study showed that the Quality of Life is reduced in patients with Diabetes
mellitus with and without Diabetic Poly Neuropathy when compared with Controls without any metabolic
disorders including Diabetes and without any types of associated Poly Neuropathy.

Key words: Diabetes Mellitus, Diabetic Poly Neuropathy, Quality of Life, WHOQOL-BREF

Introduction DM is providing to be a global public health burden as

this number is expected to rise to another 200 million
Diabetes Mellitus (DM) is a chronic metabolic
by the year 2040. Type 2 Diabetes is recognized as a
disorder characterized by persistent hyperglycemia [1].
serious public health concern with a considerable impact
It may be due to impaired insulin secretion, resistance
on human life and health expenditures. Causation of
to peripheral actions of insulin or combination of both.
Diabetes is multi-factorial which includes genetic factors
According to the International Diabetes Federation
coupled with environmental influences such as obesity
(IDF), approximately 415 million adults between the
associated with rising living standards, steady urban
ages of 20 to 79 years had Diabetes Mellitus in 2015 [2].
migration, and lifestyle changes, which has resulted in a
rapid increase in its prevalence [3-5].
Corresponding author: Diabetes affects individual’s functional capacities
Dr. Manoj Abraham M and quality of life, leading to significant morbidity and
Address- 69-1, Periyasamy Layout, premature mortality [6]. It causes a broad spectrum of
5th Cross, Rathinapuri, Coimbatore- 641027.
neuropathic complications including acute and chronic
Email: manojpt3@gmail.com
forms affecting each level of peripheral nerve, from root
Phone Number- 9600439512
to distal axon. One of the most common complications
ORCID = 0000-0002-7711-6461
 International Journal of Contemporary Medicine- January-June 2021, Vol 9, No.1
associated with Diabetes Mellitus is Diabetic Neuropath
[7]
.
Diabetic Poly Neuropathy (DPN) is a leading
cause for disability due to foot ulceration and
amputation, gait disturbance and fall related injury.
This complication is related to reduction in sensory and
motor peripheral pathways, possibly due to abnormal
neuromuscular response to postural disorders. It leads
to an inability to detect temperature, vibration, pressure
and proprioceptive changes, modifying the static and
dynamic postural balance. In addition, it significantly
reduce autonomy, individual and social well being, thus
lowers the Quality of life that substantially increases the
health costs associated with Diabetes and can even result
in early death [8,9].
The Quality of Life (QoL) derives from individual
and subjective evaluation of each person’s life, taking
into account their perception of the physical, emotional
and social well being [10]. World Health Organization
(WHO) defined QoL as individual’s perception of
their position in life in the context of culture and value
systems in which they live and in relation to their goals,
expectations, standards and concerns. Therefore, except
for person’s physical health definition of QoL includes
psychological state, level of person’s independence,
social life and personal beliefs [11]. For people living with
DM, disease management overload, co-morbidities and
complications negatively affect QoL and studies show
that QoL in diabetic patients is substantially decreased
compared to individuals without Diabetes. Regular
evaluation for QoL as a routine clinical practice could
potentially improve necessary communication among
the health care providers and their patients thereby
identify the complications and help them for long care
resulting in improving their health status [12].
Results
Table I: Demographic Variables
S.N Characteristics
1 Age
Female
2 Gender
Male
19
Materials and Methodology
This study was approved by the Institutional
Ethical Clearance Certificate, Voluntary Health
Services Hospital, Chennai. With Power Analysis, it
was estimated to have 260 samples in 3 groups. A total
of 130 subjects were identified who met the inclusion
criteria and were part of the study. 65 subjects who were
clinician diagnosed Type 2 Diabetes with Peripheral
Neuropathy were assigned as Group1-G1 (DM with
DPN). 65 subjects who were clinician diagnosed Type
2 Diabetes without Peripheral Neuropathy was assigned
as Group2-G2 (Isolated DM). 130 subjects without any
metabolic disorders including Diabetes and without any
types of associated Poly Neuropathy who consented
to take part in the study were assigned as Group3-G3
(Controls). Random Sampling technique was used to
select the samples. Cluster Randomization was used
to categorize the samples into respective groups. Other
types of associated Poly Neuropathy were excluded.
Written consent was obtained from the individuals
and the permission was obtained from the Head of the
institutions.
WHOQOL-BREF is an abbreviated version of
WHOQOL-100, used to assess changes in quality
of life. It consists of 26 questions and is based on 4
domain structures, which includes Physical health,
psychological, social relationships and environment.
This Questionnaire was used to assess the Quality of
Life among the Diabetic patients with Diabetic Poly
Neuropathy, without DPN and normal subjects without
Diabetes and DPN. The data was collected and taken for
analysis. A simple Mean and Standard Deviation is used
to analyse the Demographic variables, ANOVA and
multiple comparison test was used to analyse the data.
G1 (DM with
G2 (Isolated DM) G3 (Controls)
DPN)
n = 65 n = 130
n = 65
60.52±12.86 67.85±7.77 65.46±9.45
30 (46.2%) 32 (49.2%) 66 (50.8%)
35 (53.8%) 33 (50.8%) 64 (49.2%)
20 International Journal of Contemporary Medicine, January-June 2021, Vol.9, No. 1

Cont... Table I: Demographic Variables

3 Years of Formal education 8.69±4.39 8.34±4.37 9.11±3.16

Never married 3 (4.6%) 5 (7.7%) 0 (0%)

Currently married 27 (41.5%) 34 (52.3%) 102 (78.5%)

4 Marital status
Separated 3 (4.6%) 4 (6.2%) 0 (0%)

Widowed 32 (49.2%) 22 (33.8%) 28 (21.5%)

Present 64 (98.5%) 56 (86.2%) 116 (89.2%)

5 Co morbidities
Absent 1 (1.5%) 9 (13.8%) 14 (10.8%)

Table II ANOVA between the groups for each domain

G1 (DM with DPN) G2 (Isolated DM) G3 (Controls)

WHOQOL F - ratio p - value
n = 65 n = 65 n = 130

Domain 1 13.20±1.08 14.63±1.73 15.83±0.12 160.485 0.000*

Domain 2 29.46±2.43 31.94±2.14 32.17±1.06 28.409 0.000*

Domain 3 25.33±2.04 27.6±2.78 30.5±0.6 231.003 0.000*

Domain 4 15.87±1.53 17.83±2 19.83±0.12 303.735 0.000*

Total 83.86±5.93 92±6.75 98.33±0.94 223.451 0.000*

*significant at p<0.05
Table III Multiple Comparisons of WHOQOL-BREF scores between G1, G2 and G3

(I) Mean 95% Confidence

Dependent Group Difference Std
(J) Group Sig.
Variable Error Lower Upper
(II) (I-J)
bound bound

G2 .846* .075 0.000* 0.67 -8.33

G3
G1 1.277* .075 0.000* 1.10 -13.80

G3 .846* .075 0.000* 1.02 4.72

DOMAIN 1 G2
G1 .431* .087 0.000* .23 -7.56

G3 -1.277* .075 0.000* -1.45 10.20

G1
G2 -.431* .087 0.000* -.64 3.40

G2 -.108 .196 0.847 -.57 -1.00

G3
G1 1.354* .196 0.000* .89 -1.52

DOMAIN 2 G3 .108 .196 0.847 -.35 0.51

G2
G1 1.462* .226 0.000* .95 -0.80

G3 -1.354* .196 0.000* -1.82 1.03

G1
G2 -1.462* .226 0.000* -2.00 0.24
 International Journal of Contemporary Medicine- January-June 2021, Vol 9, No.1 21

Cont... Table III Multiple Comparisons of WHOQOL-BREF scores between G1, G2 and G3

G2 0.000* -0.0852
G3 2.562* 3.808* .188 .188 2.12 3.36
G1 0.000* -0.4237

G3 0.000* -3.01 -0.0852

DOMAIN 3 G2 -2.562* 1.246* .188 .217
G1 0.000* .73 -0.4369

G3 -3.808* 0.000* -4.25 0.2532

G1 .188 .217
G2 -1.246 0.000* -1.76 0.2401

G2 0.000* 0.8306
G3 1.646* 2.600* .111 .111 1.39 2.34
G1 0.000* -1.5230

G3 0.000* -1.91 0.5232

G2 -1.646* .954* .111 .128
DOMAIN 4 G1 0.000* .65 -0.8698

G3 -2.600* 0.000* -2.86 1.2155

G1 .111 .128
G2 -.964* 0.000* -1.86 0.5148

*significant at p<0.05

The overall WHOQOL mean scores in G1 was
83.86 ±5.93, in G2 was 92 ±6.75 and in G3 was 98.33
±0.94. There was a significant statistical difference in
WHOQOL-BREF in G1, G2 and G3 (p=0.000).Table
I describes about the demographic variables which
included the Age, Gender, years of formal education,
marital status and co morbidities. Table II describes
the Means and Standard Deviations for each Domain
in WHOQOL-BREF in all three groups along with
F – ratio was 160.485, 28.409, 231.003 and 303.735
respectively. Table III shows the multiple comparisons
of WHOQOL-BREF scores among the groups. There
22 International Journal of Contemporary Medicine, January-June 2021, Vol.9, No. 1
was a significant statistical difference in the WHOQOL-
BREF in the groups G1, G2 and G3 (p=0.000), but there
was no significant statistical difference in WHOQOL-
BREF in between G2 and G3 (p=0.847) in domain 2.
Discussion
As a part of decision making process, Quality of
Life is often proxy judged without specifically asking
the patient about it. Since these judgments can influence
the choice of treatment, it is important to know if they
are in concordance with patient’s assessments. This is
especially true for the management of chronic diseases
such as Diabetes, whereby self-management of care can
be a real burden for patients with the condition [13].
In this study, Quality of Life among the patients
with Diabetes mellitus with and without Diabetic Poly
Neuropathy when compared with controls assessed
with WHOQOL-BREF, showed a significant change in
each domain, i.e., Physical health, Psychological, Social
relationships and Environment. The WHOQOL-BREF
scores were lower in groups G1 (DM with DPN), G2
(Isolated DM) than in group G3 (Controls) in domains
D1, D3, and D4. Only in domain D2, there is no
difference between groups G2 and G3.
Patients with Diabetes have worse Quality of Life
compared to persons without Diabetes, especially those
with diabetic neuropathy [14]. The Physical domain of
QoL might be decreased because of the presence of co-
morbidities such as Hypertension, Cervical Spondylitis,
Osteoarthritis, Low back pain and Periarthritis shoulder.
Studies also reported that presence of co-morbidities as
a predictor of poor QoL. The diabetic patients without
complications had a better QoL compared to the patients
with diabetic complications and as the number of
complications increased the QoL score decreased [15].
It is known that depression has a harmful impact on
glycemic control and in turn, poorly controlled diabetes
intensifies depressive symptoms and has a potentially
significant impact on QoL [16]. Not only depression but
also changes in the perception about the feelings and
the self image of individual can significantly reduce
their QoL. Surprisingly in this study we did not find
any change in Domain 2 i.e., Psychological, between
the patients with isolated Diabetes mellitus (G2) and
controls (G3). They showed better scores in domain 2,
than in patients with Diabetes mellitus with Diabetic
Poly Neuropathy (G1).
The impact of the disease and of treatment on all
chronic patients QoL and lifestyle is a key concern for
both the patients themselves and their physicians. This
is particularly relevant in the case of diabetic patients:
the physical, psychological and social burden of
diabetes affects patient’s self care behaviours, disease
management, therapeutic adherence and consequently
QoL [17].
With advancement of age, the number of
complications and incapacities increases, leading to a
decrease in the autonomy that influences quality of life.
In general, studies already performed suggest that the
presence of chronic complications of DM is associated
with significant decrease in the quality of life of
individuals with DM, and the quality of life decreases
as the number of chronic complications increases [18,19].
Conclusion
The findings in this study showed that the Quality of
Life is reduced in patients with Diabetes mellitus with
and without Diabetic Poly Neuropathy when compared
with Controls without any metabolic disorders including
Diabetes and without any types of associated Poly
Neuropathy. It is recommended that Quality of Life
has to be regularly evaluated in the chronic diseases,
so that their health status can be improved and treated
accordingly to avoid complications.
Acknowledgement: The Authors sincerely thank
Dr. Ennapadam S Krishnamoorthy, Founder and Chief
Consultant of NeuroKrish, Chennai, and the Expert team
members for their support and logistical help to conduct
this research.
Funding: No funding was received for conducting
this study
Conflict of Interest: The authors have no conflict
of interest to declare that are relevant to the content of
this article
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StatPearls. StatPearls Publishing, Treasure Island
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2. Zheng Y, Ley SH, Hu FB. Global etiology and
epidemiology of type 2 diabetes mellitus and
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3. Onyango EM, Onyango BM. The rise of non-
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4. Aditya Oruganti, Avinash Kavi, Padmaja R
Walvekar. Risk of developing Diabetes Mellitus
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5. Kaveeshwar SA, Cornwall J. The current state
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6. Ramtahal R, Khan C, Maharaj-Khan K, Nallamothu
S, Hinds A, Dhanoo A, Yeh HC, Hill-Briggs F,
Lazo M. Prevalence of self reported sleep duration
and sleep habits in type 2 diabetes patients in South
Trinidad. J Epidemiol Glob Health.2015 Dec; 5(4
supply 1): S35-43
7. Juster Switlyk K, Smith AG. Updates in Diabetic
Peripheral Neuropathy. F1000Res. 2016; 5:
F1000Faculty Rev-738. Published 2016 Apr 25.
doi:10.12688/f1000research.7898.1
8. Tesfaye S: Diabetic Neuropathies: Update on
Definitions, Diagnostic Criteria, Estimation of
severity and Treatments. Diabetes Care, 2010 Oct,
33(10): 2285-2293
9. Ernandes RC, Brech GC, Luna NMS, Bega A,
Guimarães DS, Bocalini DS, Scherrer G Jr., Greve
JM, Leme LEG, Alonso AC. The impact of diabetic
neuropathy on quality of life and postural balance
in Brazilian older adults. Acta Ortop Bras. [online].
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10. Jorgetto JV, Franco LJ. Evaluation of the quality of
living of individuals with diabetes mellitus through
the use of WHOQOL-100. J Clin Endocrinol Res.
2018; 1(1): 17-23
11. The World Health Organization Quality of Life
Assessment (WHOQOL): Development and
General psychometric properties. Soc Sci Med.
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12. Prajapati VB, Blake R, Acharya LD, Seshadri S,
Assessment of Quality of Life in type II diabetic
patients using the modified diabetes quality of life
(MDQoL) – 17 questionnaire. Braz J Pharm Sci,
2017; 53(4)
13. Stanislava Yordanovaa , Valentina Petkovaa
, Guenka Petrovaa , Milen Dimitrova , Emilia
Nasevab , Maria Dimitrovaa and Elina Petkova,
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14. Uazman Alam, Asher Fawwad, Fariha
Shaheen, Bilal Tahir, Abdul Basit, and Rayaz
A. Malik, Improvement in neuropathy specific
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19. Gomes AR, Santos L. The prevalence of
complications of diabetes mellitus in ACeS Santo
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24 International Journal of Contemporary Medicine, January-June 2021, Vol.9, No. 1 DOI Number: 10.37506/ijocm.v9i1.2928

The Deadly Duo-A Combination of Allergy and Acute

Coronary Syndrome A Case of Kounis Syndrome Type 1

Ramkumar Rajappan1, Bivin Wilson2, Priya Kubendiran2, Rajpal K.Abhaichand3, Abhishek Kasha4
1
Senior Medical Officer, 2Consultant Interventional cardiologist, 3 Chairman and Consultant Interventional
Cardiologist, 4 Cardiology Trainee, Department of Cardiology, GKNM Hospital, Coimbatore, India

Abstract
Kounis syndromewas first described by Kounis and Zavras in 1991, as the concurrent occurrence of
acute coronary events with an allergic or a hypersensitivity response. Mast cell activation and release of
inflammatory mediators have shown to induce coronary spasm, plaque erosion and even stent thrombosis.
A 41 years old male, smoker was admitted with chest discomfort and features suggestive of myocardial
infarction. His ECG showed ST elevation and T inversion in I, aVL. High sensitive troponin I was elevated
and echocardiogram was normal. Four days ago, he had a history of redness and itching all over the body
and was treated for allergic dermatitis. He had a family history of urticaria also. Coronary angiogram
revealed no major flow limiting coronary artery disease. Kounis syndrome type 1 was diagnosed and he was
discharged on oral steroids and cardiac drugs. We always have to think of Kounis syndrome when treating
a young patient with allergy or anaphylaxis and concurrent acute coronary syndrome. Prompt recognition is
important as treatment is significantly different.

Key Words: Allergic dermatitis,Kounis syndrome,Mast cells, Myocardial Infarction, allergic acute coronary
syndrome.

Case History
A 41 years old male, who was a smoker for
more than 10 years, developed chest discomfort and
breathlessness at rest. His pulse rate was 66/min, blood
pressure-140/80 mmHg, respiratory rate-22/min, and
saturation of 98% in room air. His cardiovascular,
respiratory, abdominal, and central nervous system
examination were normal. His electrocardiogram
showed sinus rhythm, with STelevation and T inversion
in I,aVL and tall T waves in chest leads (figure 1). His
cardiac enzyme was elevated (high sensitive Troponin
I -113 pg/ml).Echocardiogram showed no regional wall
motion abnormality with adequate ventricular function.
With the available evidence, he was diagnosed to have
high lateral myocardial infarction with spontaneous
recanalization.
He gave a history of redness and itching all over
Corresponding Author:
Dr. Bivin Wilson,G.
Kuppuswamy Naidu Memorial Hospital, Coimbatore,
India.+919488161261, bivinwilson@gmail.com.
the body, four days back. He was diagnosed as allergic
dermatitis and was treated with IV antihistamines and
steroids. His father and elder brother had a history of
urticaria. Skin examination showed urticarial lesions
over the anterior chest and back (figure 2). His IgE
level was high-253 IU/ml. Serum C3,C4 were normal.
Dyslipidemia(LDL-202 mg/dl, total cholesterol-258 mg/
dl) was present. He had polymorphonuclear leukocytosis.
He was treated with standard acute coronary syndrome
measures, along with IV steroids, antihistamines, and
mast cell stabilizers.
Coronary angiogram was done which revealed no
major flow-limiting coronary artery disease with grade
III myocardial bridging in left anterior descending
artery (Figures 3-5). He was later given per oral
steroid in tapering dose, single antiplatelet, and statins.
His urticarial skin lesionssubsequently improved.
From thehistory, clinical examination,and relevant
investigations, we diagnosed this, as a case of Kounis
Syndrome type I. Because of the normal angiogram,
he is probably having Type I Kounis syndrome with
coronary spasm leading to myocardial infarction (MI)
and enzyme elevation.
 International Journal of Contemporary Medicine- January-June 2021, Vol 9, No.1 25

Figure 1-Electrocardiogram showing ST elevation of 1 mm and T inversion in I,aVL and tall T waves in Chest leads.
Figure 2- urticarial lesions. Figure 3 to 5-Coronary angiogram showing normal coronaries.
26 International Journal of Contemporary Medicine, January-June 2021, Vol.9, No. 1
Discussion
Kounis syndrome was first described by Kounis and
Zavras in 1991(1), asthe concurrent occurrence of acute
coronary events withan allergic or hypersensitivity
response. The condition hasthree variants(2), i.e. type
1 – coronary spasm;type 2 – coronary thrombosis; and
type 3 –drug-eluting stent thrombosis. Management
differs depending on the type. Inflammatory mediators
are released mainlyfrom activated mast cells and via
bidirectionalstimuli, macrophages, and T-lymphocytes.
Activated mast cells accumulate in large numbers
in the areas ofplaque erosion or rupture in patients
sufferingfrom acute MI(3).
• Type 1 variant comprises of patients with normal
coronary arteries(4) withoutpredisposing risk factors, in
whom the acute release ofinflammatory mediators can
induceeither coronary artery spasm without elevation of
cardiac enzymesor coronary artery spasm progressing
toacute MI with raisedcardiac enzymes and troponins.
• Type 2 variant includes patients with quiescent, pre-
existing atheromatous lesions, in whom inflammatory
mediators can induce either coronary artery spasm or
acute MI.
• Type 3 variant comprises of patients with
coronarythrombosis (including stent thrombosis) and
there is the presence of eosinophils and mast cells in the
aspirated thrombus specimensstained with hematoxylin-
eosin and Giemsarespectively.
Measurement of histamine, released by mast cell
degranulationwithin
5 - 10 minutes is helpful, but remains elevated
foronly 30 - 60 minutes and therefore hasvery limited
value. Serum tryptasehas been identified as a reliable
marker ofanaphylaxis(5). Adiagnosis of Kounis syndrome
can still be made based on theclinical presentation,
regardless of the documented laboratory evidence and
treatment carriedout accordingly.
Conclusion
Ours is a case of Type I variant of Kounis syndrome,
with normal coronary arteries in whom the allergic
reaction has led to coronary artery spasm leading to
myocardial infarction in D1 territory. Treatment with
IV steroids, mast cell stabilizers and antihistamines has
helped this patient. This syndrome isotherwise called as
an allergic acute coronary syndrome.
Conflict of Interest: Nil
Source of Funding: Self
Ethical Clearance: Taken from Institutional Ethical
Committee, GKNMH.
References
1. Kounis NG, Zavras GM. Histamine-induced
coronary artery spasm: the concept of allergic
angina.  The British Journal of Clinical
Practice. 1991;45(2):121–128. 
2. Kounis NG. Coronary hypersensitivity
disorder: the Kounis syndrome.  Clinical
Therapeutics. 2013;35(5):563–571.
3. J. Steffel, A.Akhmedov, H. Greutert, T. F. Luscher,
and F. C. Tanner. “Histamine induces tissue factor
expression”. Circulation.Vol. 112, no. 3, pp. 341–
349, 2005.
4. L. L. Reber, J. D. Hernandez, and S. J. Galli.
“The pathophysiology of anaphylaxis,” Journal of
Allergy and Clinical Immunology. Vol. 140, no. 2,
pp. 335–34810, 2017.
5. Kounis NG, Mazarakis A, Tsigkas G. Kounis
syndrome: a new twist on an old disease. Future
Cardiology; 2011; 7(6):805-24.
DOI Number: 10.37506/ijocm.v9i1.2929 International Journal of Contemporary Medicine- January-June 2021, Vol 9, No.1 27

A Rare Case of Pneumonia and Haemoptysis Caused by

Citrobactor Freundii in a Young Immunocompetent Male

Sushil Upadhyay
Senior Consultant Chest Physician, Holy Family Hospital, Okhla Road, Delhi

Abstract
Citrobacter infections are often nosocomially acquired, seen in patients with significant underlying diseases
and isolates are commonly drug-resistant.A rare clinical syndrome of haemoptysis with underlying
pneumonia caused by Citrobactor freundii in a immunocompetent young male is presented.

Key Words: Citrobactor, Pneumonia, Immunocompetent

Introduction history.He was admitted under general physician.

Investigations revealed normal hemogram,renal and liver
Citrobacter genus belongs to family of
biochemistries,coagulation parameters.Chest xray(fig1)
Enterobacteriacea and comprises of 11 different species
showed right upper zone hazy airspace opacity.CT
of straight, facultative anaerobic, motile,Gram-negative
thorax(Fig2) confirmed small patch of consolidation
bacilli which are oxidase negative and utilize citrate as
in posterior segment of right upper lobe .He received
sole carbon source1.They are commonly found in water,
amoxiclav and azithromycin with haemostatics and
soil, food, and the intestinal tracts of animals and humans2.
pantoprazole.He was referred to respiratory specialist
Citrobacter infections typically occur in hospital settings
for bronchoscopy.Bronchoscopy(Fig3) showed scanty
in patients with multiple comorbidities and seldom cause
bleeding from right upper lobe posterior segment without
disease in the general population3.Urinary tract is the
any sign of inflammation.Bronchial washings were sent
most common site of infection and pneumonia is reported
for detailed investigations.Patient was discharged the
as least common form of infection by Citrobactor
very next day on oral amoxyclav as he was asymptomatic.
species4. Community acquired human infections by
However he presented again with haemoptysis 2 days
Citrobactor species are extremely rare and occur at
after leaving the hospital.Chest xray revealed same RUZ
the extremes of age or in the immunocompromised5 It
opacity.Respiratory review was solicited. Bronchial
has been rarely cultured in the bronchoscopy specimen
washing which were sent on previous admission were
done for the evaluation of hemoptysis6. The case is
now available.ZN stain and Gene Xpert were negative
being reported because of extremely rare combination
for Mycobacterium tuberculosis.Cytology was negative
of immunocompetent host from community setting
for malignant cells.Bacterial culture had grown
presenting with haemoptysis,diagnosed as right upper
Citrobactor freundii which was resistant to betalacatam/
lobe pneumonia on imaging, further confirmed by
lacatamase,cefalosporins,aminogycosides and even
bronchoscopy and finally yielding Citrobactor freundi
carbapenems.It was sensitive only to quinolones,
on culture of bronchial washings.
tetracycline, colistin, tigicycline and cotrimoxazole
(Fig5).Antibiotics were revised and levofloxacin was
Case Report
given.He was discharged on oral tab of 750mg of
Forty four year old male presented in emergency Levofloxacin once a day.Patient was followed up in out
department(ED) with hemoptysis.He complained of one patient department after 5 days.He was asymptomatic
episode of fever 5 days prior followed by expectoration and repeat chest xray(Fig4) showed resolved RUZ
of blood from mouth.Quantity of blood varied between 1 opacity.
tea-spoon full to 1 table spoon per event which occurred
2-3 times in a day.He had no past medical or surgical
28 International Journal of Contemporary Medicine, January-June 2021, Vol.9, No. 1

Fig( 1&2) Chest Xray and CT scan:RUL faint consolidation

Discussion risk of acquiring  Citrobacter  infections. The first one

Citrobacter species are straight, facultative
anaerobic, Gram-negative bacilli and are typically motile
by means of peritrichous flagellae.. This genus was
proposed in 1932 by Werkman and Gillen.. In year 1993,
Brenner et al. classified  Citrobacter  into 11 genomic
species by DNA hybridization. The leading three species
causing human infections are  C. freundii,  C. koseri,
and  C. Braakii7. Citrobacter  species are commonly
found in water, soil, food, and the intestinal tracts of
animals and humans2. Two groups of patients are at
is neonates, who may develop sepsis and meningitis
and brain abscess (usually less than 2 months of age).
The second group is debilitated, aged (≥ 65years) or
immunocompromised patients5. The infection may occur
as sporadic cases or nosocomial outbreaks. Among the
various sites of infection, the urinary tract is the most
common, followed by the abdomen, skin/soft tissues
(including surgical site infection), and pneumonia. A
large surveillance study demonstrated that 0.8% of Gram-
negative infection was caused by  Citrobacter spp.3. In
 International Journal of Contemporary Medicine- January-June 2021, Vol 9, No.1
the hospital settings,  Citrobacter  spp. might account
for 3-6% of all Enterobacteriaceae causing nosocomial
infection.
Mohanty etal from a tertiary care hospital in northern
India, isolated Citrobactor from routine diagnostic
testings from 205 patients from Jan till Dec 2004 .They
observed that infection was nosocomially acquired in
94.6% patients. One hundred eighty one (88.3%) patients
had significant underlying illnesses. Culture yielded
Citrobacter koseri in 185 (90.2%) and Citrobacter
freundii in 20 (9.8%) patients. The distribution of
isolates was as follows: urine (46.2%), respiratory tract
(16.3%), blood (15.8%), pus (12.1%) and sterile body
fluids (9.3%). Drug resistance was observed to be more
in C. koseri as compared to C. Freundii11
Ashwin Songara et al from India studied role of
bronchoscopy in evaluation of patients with hemoptysis.
They found Citrobactor freundi to grow in bronchial
washings in 2.85% of patients6.
In a study of community acquired pneumonia in
elderly(>65yrs) Anupam Pillai etal reported Citrobactor
freundii as causative agent in 2 cases out of 65 study
patients8
Miguel Angel Ariza-Prota etal in year 2015 reported
pneumonia and empyema in a72 year old Spanish male
and claimed to be first reported case of community
acquired pneumonia in a immunocompetent male caused
by Citrobactor koseri9.
Kelly Pennington et al from Mayo clinic Rochester
in year 2016 reported pneumonia attributable to
Citrobactor koseri in 60year old man who on further
investigation was found to have adenocarcinoma of
lung10.
To the authors knowledge, this is the first reported
case in the literature where a young immunocompetent
male presents with community acquired pneumonia and
haemoptysis caused by Citrobactor freundii.
Patients with  Citrobacter  infection can be
identified and confirmed only by culture. Different
species can be differentiated by biochemical tests2. The
treatmentof Citrobacter infections follows the principles
for treatment of other  Enterobacteriaceae  infections.
Aminoglycosides, fluoroquinolones, carbapenems, and
29
the fourth-generation cephems, such as  cefepime  and
cefpirome, are the preferred therapeutic agents for  C.
freundii  infections. Once a specific strain is isolated
from a patient, therapeutic agents should be selected
according to the  in vitro  susceptibility results of that
strain.The , the site of infection also influences choice
of agents12.
Conclusion
Citrobactor freundi causing community
acquired pneumonia presenting as hemoptysis in a
immunocompetent host is a rare infection. Culture and
sensitivity of the sample from involved organ is the key
to definitive diagnosis and successful treatment.
Ethical Clearance: NA
Conflict of Interest: Nil
Source of Funding: Self
References
1. Janda J. M., Abbott S. L., Cheung W. K. W.,
Hanson D. F. Biochemical identification of
citrobacteria in the clinical laboratory.  Journal of
Clinical Microbiology. 1994;32(8):1850–1854
2. Arens S., Verbist L. Differentiation and
susceptibility of Citrobacter isolates from patients
in a university hospital. Clinical Microbiology and
Infection. 1997;3(1):53–57
3. Schwartz D. A. Citrobacter infections. In: Connor
D. H., Chandler F. W., Schwartz D. A., Manz H.
J., Lack E. E., editors.  Pathology of Infectious
Diseases. Stanford, Connecticut: Appleton and
Lange. 1997. pp. 513–516
4. Samonis G, Karageorgopoulos DE, Kofteridis DP,
Matthaiou DK, Sidiropoulou V, Maraki S, Falagas
ME.  Citrobacter  infections in a general hospital:
characteristics and outcomes. Eur J Clin Microbiol
Infect Dis 2009;28:61-68
5. Lipsky BA, Hook EW III, Smith AA, Plorde JJ.
Citrobacter infections in humans: experience at the
Seattle Veterans Administration Medical Center
and a review of the literature. Rev Infect Dis
1980;2:746-760
6. Ashwin Songara, Rohit Mukherjee, Swapnil
Shikha, Awadesh P. S. Solanki, Tanay Joshi,
Deepika Patel.Role of fiberoptic bronchoscopy in
30 International Journal of Contemporary Medicine, January-June 2021, Vol.9, No. 1
evaluation of hemoptysis. Int J Res Med Sci. 2016
Jul;4(7):2576-2582
7. Brenner DJ, Grimont PAD, Steigerwalt AG, Fanning
GR,  Ageron E,  Riddle CF.  Classification of
Citrobacteria by DNA hybridization.  Int J Syst
Bacteriol 1993; 43: 645– 58
8. Anupa Pillai, Shwet Sabnis, Tushar Kanti Biswas.
A study of Community Acquired Pneumonia in the
Elderly. IAIM, 2019; 6(12): 1-9.
9 Miguel Angel Ariza-Prota,  Ana Pando-
Sandoval,  Marta García-Clemente,  Ramón
Fernández, and Pere Casan. Community-Acquired
Pneumonia and Empyema Caused by  Citrobacter
koseri  in an Immunocompetent Patient.Case
Reports in Pulmonology Vol 2015.pp:1-6
10. Kelly Penington,Martin Van Zyl,Patricio Escalante.
Citrobactor koseri pneumonia as initial presentation
of underlying pulmonary adenocarcinoma.Clin
Med Insights Case Rep 2016;9:87-89
11. Mohanty S., Singhal R., Sood S., Dhawan B.,
Kapil A., Das B. K.  Citrobacter  infections in a
tertiary care hospital in Northern India. Journal of
Infection. 2007;54(1):58–64.
12. Shih CC, Chen YC, Chang SC, Luh KT, Hsieh WC.
Bacteremia due to Citrobacter species: significance
of primary intraabdominal infection. Clin Infect
Dis 1996;23:543-549.
DOI Number: 10.37506/ijocm.v9i1.2931 International Journal of Contemporary Medicine- January-June 2021, Vol 9, No.1 31

Association of XmnI Polymorphism with Fetal Hemoglobin

Level in Sudanese Patients with Sickle Cell Disease

Tarig Osman Khalafallah Ahmed1, Abeer Alshazaly Abdulrahman Altag2 Ahmed Abdalla Agab Eldour3,
Anass M. Abbas4, Manar G.Shalabi4, Asaad Ma.Babker 5
1
Assistant Professor, Faculty of Medical Laboratory Science, Department of Hematology, University of Kordofan,
El-Obeid, Sudan, 2Scientist, Obeid Teaching Hospital, Ministry of Health, El-Obeid, Sudan, 3Professor, Faculty
of Medicine, Department of Pathology, University of Kordofan, El-Obeid, Sudan, 4Assistant professor ,Clinical
Laboratory Sciences Department, College of Applied Medical Sciences- Jouf University, KSA, 5Associate
Professorof Hematology ,Department of Medical Laboratory Sciences, College of Health Sciences, Gulf Medical
University, Ajman, United Arab Emirates

Abstract
Background: Sickle cell disease (SCD) is an inherited blood disorder that affects red blood cells. The study
of various modulating factors, and genetic factors affecting the clinical severity of the SCD is an interesting
research focus especially in communities with a distinct genetic background. The XmnI polymorphism is
a common genetic variation that was reported in previous studies to increase fetal hemoglobin (HbF) level.
This was a descriptive cross-sectional study, conducted in El-Obeid city in Northern Kordofan state, western
Sudan, during the period from August to November 2016. The Xmn1 polymorphic site was determined by
polymerase chain reaction. Data was analyzed using SPSS software program version 20. P-value of 0.05
and below was considered of significance. In present study HbF level among normal individuals AA , shown
significant difference (p<0.05) between presence of Xmnl +/+ and absence of Xmnl -/- site. in patients with
SS , the HbF level was higher in those who had one or two Xmnl sites as compared to those with the site
absent . In patients with sickle cell trait AS and AA, only the presence of the one and two Xmnl site (+/+)
compared to the absence of the site (-/-) was associated with significant increase in the HbF level. There is
a close link between the Xmn1 polymorphism site and HbF level. A wide range of HbF level was obtained
both in the present and absence of this site. Further studies with a large sample size as well as analysis BS
haplotypes among the patient with sickle cell anemia population are needed for better understand of possible
association .

Keywords: XmnI Polymorphism, SCD, Sickle cell disease, Fetal hemoglobin, HbF

Introduction called sickle cell anemia or Hb SS, is polymerization of

deoxy-Hb S resulting in the formation of multistranded
Sickle cell disease (SCD) is an inherited autosomal
fibers that create a gel and change the shape of RBCs
recessive disorder with presence of Hb S in blood.
from biconcave discs to elongated crescents. The
This disease affects millions of peoples globally which
polymerization/sickling reaction is reversible following
results in serious complications due to vasoocclusive
reoxygenation of the hemoglobin. Thus, an RBC can
phenomenon and hemolysis .Sickle hemoglobin (Hb S)
undergo repeated cycles of sickling and un sickling3.The
is a structural variant of normal adult hemoglobin (Hb
C-T substitution at position – 158 of the YG globin gene
A) caused by a mutation in the HBB gene that leads to
referred to astheXmn1-y polymorphism is reported to
the substitution of valine for glutamic acid at position
be a common sequence variant inall population groups,
6 of the β-globin’s subunit (βS) of the hemoglobin
present at a frequency of 0.32 to 0.35. 4.Clinical studies
molecule1. The pathological process in sickle cell
have shown that under conditions of hematopoietic stress,
disease is caused by the sickling phenomenon2.The basis
for example in homozygous B-thalassemia and sicklecell
of sickling in patients homozygous for the disorder,
32 International Journal of Contemporary Medicine, January-June 2021, Vol.9, No. 1

disease the presenceof the Xmn1 – YG site favors a
higher Hb F response This could explain why the same
mutations on different B chromosomal backgrounds are
associated with disease of different clinical severity5.
The yG – 158(C – T) polymorphism plays important
function in the disease severity of Sickle cell anemia. The
Xmn1 restriction site at – 158 position of the yG – gene
isassociated with increased expression of the yG – goblin
gene and higher production of HbF 6.In Sudan several
studies were conducted among patient with sickle cell
disease 7,8,9, but there are no studies to assess association
between Xmn1 polymorphism and HbF level in sickle
cell disease patient the prevalence in different area in
Sudan. The aim of present study to association of XmnI
polymorphism with fetal hemoglobin level in Sudanese
patients with sickle cell disease.
Material and Methods
This was a descriptive cross-sectional study,
conducted in El-Obeid city in Northern Kordofan
state, western Sudan, during the period from August
to November 2016. Known patients with sickle cell
anemia attending Elobied children specialized hospital
and Elkowity Hospital. Permission was taken from the
committee of Kordofan university , El-Obeid Teaching
Hospital and Elkowity Hospital, also consent was taking
from patients and co–patients in Hospital.100 patient
volunteer was selected using simple random technique.
2.5 ml of venous blood was collected from each participant
under complete antiseptic condition. Hemoglobin F
was measured by modified Betke Method. The Xmn1
polymorphic site was determined by polymerase chain
reaction. Data was analyzed using SPSS software
program version 20. P-value of 0.05 and below was
considered of significance.The sickle cell mutation was
confirmed by amplifying the 5’ region of the B. Globin
genes followed by restriction digestion with Ddel A
650- bp fragment 5’to the YG sense was amplified using
the Primer5’AACTGTTFCTTTATAGGATTTT-3
and 5’AGGAGCTTATTGATAACCTCAGAC-3. The
amplification condition were initial denaturation 94c for
5 min followed by 30 cycles of 94c for 1 min and 55c
for 1 min 72c / min. with a final extension of 5min at 72c
the PCR product was digested with three unit of Xmn1
restriction enzyme and separated by electrophoresis on
3% agarose gel.
Result
Significantly different comparing Xmnl +/+ with
Xmnl +/- (p<0.05) or comparing Xmnl +/+ with -/-
(p<0.05) in sickle cell patients (SS), the HbF level was
significantly higher in those who had two Xmnl sites
(p<0.05) compared to those with only one Xmnl site and
with absent site (p<0.05) in patients with SS who had
one Xmnl site and Xmnl -/- site there is no difference
in HbF level(Table I). .In AS patient’s presence of two
Xmnl +/+ site compared with one Xmnl site (p<0.05) and
one Xmnl site compared with Xmnl -/- site (p<0.05) had
significant higher level of HbF(Table II). Significantly
different comparing Xmnl +/- with Xmnl -/- (p<0.05)
or comparing Xmnl +/+ with +/- (p<0.05) in normal
control (AA), (Table III).

Table 1: The HbF percentage and Xmnl in SS group.

Xmnl SS(n=60) HbF(mean ± SD) P.value

+/+ 16(27%) 81.97 ± 3.30 p<0.05

+/- 20(33%) 21.84 ± 13.83 p<0.05

-/- 24(40%) 20.28 ± 10.86 p<0.05

 International Journal of Contemporary Medicine- January-June 2021, Vol 9, No.1 33

Table II: The association betweenHbF percentage and Xmnl in AS group.

Xmnl AS(n=30) HbF(mean ± SD) P.value

+/+ 4(13%) 17.45 ± 0.58 p<0.05

+/- 10(34%) 0.8 ± 0.57 p<0.05

-/- 16(53%) 0.04 ± 0.11 p<0.05

Table III: The association between HbF percentage and Xmnl in AA group.

Xmnl AA(n=10) HbF(mean ± SD) P.value

+/+ 2(20%) 0.95 ± 0.63 p<0.05

+/- 5(50%) 0.37 ± 0.22 p<0.05

-/- 3(30%) 0.02 ± 0.08 p<0.05

Discussion presence of this polymorphism is associated with high

The XmnI polymorphism is a common genetic
variation that was reported in previous studies to increase
HbF level and therefore ameliorate the severity of the
sickle cell disease.Our study shows that a polymorphism
of the XmnI was found to be associated with higher
expression of HbF in sickle cell and sickle cell trait
patients. Several studies confirmed the association
between XmnI and fetal hemoglobin 10,11.Appositive
association was observed between the HbF level and
the presence of Xmn1 site in SS and sickle thalassemia
groups Recently, other genetic association studies
shown that several single nucleotide polymorphisms,
associated with variation in the expression of HbF in
sickle cell disease12.The XmnI polymorphism is known
to influence the γG gene expression in sickle cell anemia
and to increased HbF concentrations when they are under
conditions of erythropoietic stress13. Study conducted by
FarizKahhaleh et.al to assist the Association of Xmn1
polymorphism and consanguineous marriage with fetal
hemoglobin in Syrian patients with sickle cell disease
they concluded that a strong evidence on the importance
of Xmn1 polymorphism and consanguineous marriage,
among other factors, in the prediction of clinical severity
and hydroxyurea response in SCD patients14. In sickle
cell disease and sickle cell trait patients of Elobied, the
HbF level. This is the first report of the frequency of the
-158 XmnI γG-globin polymorphism in patients with SS
and AS in Elobied.
Conclusion
There is a close link between the Xmn1
polymorphism site and HbF level. A wide range of HbF
level was obtained both in the present and absence of
this site. Further studies with a large sample size as well
as analysis BS haplotypes among the patient with sickle
cell anemia population are needed for better understand
of possible association.
Acknowledgement: The authors are warmest thanks
to all who participated in this study and especial thank to
Elobied Teaching Hospital and Elkowity Hospital.
Conflict of Interest: All authors have none to
declare
Ethical Clearance: Taken
Source of Funding: Self
Reference
1 Knar M, Dangi CBS, Singh M.An overview
on sickle cell disease profile. Asian Journal of
34 International Journal of Contemporary Medicine, January-June 2021, Vol.9, No. 1
Pharmaceutical and Clinical Research.2013;
6(1):25-37.
2- Dean J, Schlecter AN. Sickle cell anemia, molecular
and cellular basis of therapeutic approaches. New
England Journal of Medicine.1978; 299:752-63.
3- Forget B.G, Bunn H.F. Classification of the
disorders of hemoglobin. Cold Spring Harbor
Perspectives in Medicine.2013;3(2):a011684.
4- Pissard S and Beuzard Y. A potential regulatory
region for the expression of fetal hemoglobin in
sickle cell disease. Blood. 1994.84:331-338.
5- Barbosa CG, Goncalves-Santos NJ, Souza-Ribeiro
SB, Moura-Neto JP, Takahashi D, Silva DO,
Hurtado-Guerrero AF, Reis MG, Gonçalves MD.
Promoter region sequence differences in the A
and G gamma globin genes of Brazilian sickle cell
anemia patients. Brazilian journal of medical and
biological research. 2010 ;43(8):705-11.
6- Bhagat, S., Patra, P.K. and Thakur, A.S..
Association between XmnI polymorphism and
HbF level in sickle cell disease patients from
Chhattisgarh. International journal of biomedical
science.2012:8(1), p.36.
7- Mohamed, E.A., Elgari, M.M., Babker, A.M.
and Waggiallah, H.A., . Comparative study of
hypercoagulability change in steady state and
during vaso-occlusive crisis among Sudanese
patients living with sickle cell disease. African
Health Sciences, 2020:20(1), pp.392-396.
8- Shireen, Z.N., Elshazali, W.A. and Hiba, K.,
Association of BCL11A Genetic Polymorphisms
with Fetal haemoglobin Level in Sudanese Patients
with Sickle Cell Anaemia. Journal Genomics &
Gene Study.2019 2(1), p.2.
9- Sabahelzain, M.M. and Hamamy, H., 2014. The
ethnic distribution of sickle cell disease in Sudan.
Pan African medical Journal, 18(1).
10- Shimmoto MM, Vicari P, Fernandes AC,
Guimarães GS, Figueiredo MS. XmnI
polymorphism is associated with fetal hemoglobin
levels in hypoplastic syndromes. Sao Paulo Med
J. 2006 Mar 2;124(2):110-1. doi: 10.1590/s1516-
31802006000200012. PMID: 16878196.
11- Mannoor, K., Hossain, M., Noor, F.A., Bhuyan, G.S.
and Qadri, S.S., 2019. Role of XmnI polymorphism
in HbF induction in HbE/β and β-thalassaemia
patients. Bangladesh Medical Research Council
Bulletin, 45(3), pp.133-142.
12- Simpore J, Pignatelli S, Barlati S, Musumeci S.
Modification in the frequency of Hb C and Hb S in
Burkina Faso: an influence of migratory fluxes and
improvement of patient health care. Hemoglobin.
2002 ;26(2):113-20.
13- Bhagat S, Patra PK, Thakur AS. Association
between XmnI Polymorphism and HbF Level in
Sickle Cell Disease Patients from Chhattisgarh.
International Journal of Biomedical Science. 2012
;8(1):36-9.
14- Kahhaleh, F., Sulaiman, M. A., &Alquobaili, F.
(2019). Association of Xmn1 polymorphism and
consanguineous marriage with fetal hemoglobin
in Syrian patients with sickle cell disease. Cogent
Medicine, 6(1), 1639243. https://doi.org/10.1080/2
331205X.2019.1639243.
DOI Number: 10.37506/ijocm.v9i1.2932 International Journal of Contemporary Medicine- January-June 2021, Vol 9, No.1 35

Association of Glycated Hemoglobin and Dyslipidemia Inpatients

with Type 2 Diabetes Mellitus in a K.M.C.H. Katihar, Bihar-A
Retrospective, Cross-Sectional and Descriptive Study

Amresh Kumar1, Jiut Ram Keshari2, Manish Kumar3, Manish Kumar4

1
Assistant Professor, Dept. of Biochemistry, DMCH, Laheriasarai, Darbhanga, 2Additional Professor, Dept. of
Biochemistry, IGIMS, Patna, 3Associate Professor, Dept. of Pharmacology, IGIMS, Patna, 4Additional Professor,
Department of Physiology, IGIMS, Patna

Abstract
Introduction: Dyslipidemia is one of the major risk factors for cardiovascular disease in diabetes
mellitusType2.The aim of the study was to understand the pattern of dyslipidemia and its association with
glycated hemoglobin (HBA1C) among Type 2 diabetic.

Materials and Methods: This was a retrospective cross-sectional study to assess the relationship between
glycemic control (as reflected by HBA1C) and serum lipid profile in Type2 diabetic patients which included
a total of 200 Type2 diabetic patients (104 males; 96 females; mean age years 62.91). Venous blood samples
were collected from all the patients after at least 8 h fasting.

Results: HBA1C, fasting blood glucose (FBG), total cholesterol, triglycerides (TG), high-density lipoprotein
(HDL) cholesterol, and low-density lipoprotein (LDL) cholesterol were analyzed. In male and female
patient, serum levels of HBA1C, FBG, and LDL were not significantly different. As compared to males,
female patients showed significantly higher serum cholesterol and HDL but significantly lower TG levels.
Correlation between HBA1C and FBG was highly significant in this study. Both HBA1C and FBG exhibited
direct correlations with cholesterol, TG, and LDL and inverse correlation with HDL; the magnitude of
significance for all these lipid parameters being greater with HBAIC than FBG. There was a linear
relationship between HBA1C and dyslipidemia. The levels of serum cholesterol and TG were significantly
higher and of HDL significantly lower in patients with worse glycemic control as compared to patients with
good glycemic control.

Conclusion: The findings of this study clearly showed that HBA1C is not only a useful biomarker of long-
term glycemic control but also a good predictor of lipid profile.

Key words: Cholesterol, Diabetes mellitus, Dyslipidemia, Glycated hemoglobin, High-density lipoprotein
cholesterol, Low-density lipoprotein cholesterol, Triglycerides

Corresponding author:
Dr. Manish Kumar
Associate Professor, Department of Pharmacology,
Indira Gandhi Institute of Medical Sciences,
Skeikhpura, Patna-800014, Bihar
Mob: 9304093698, Email: manu072@gmail.com
Introduction
Diabetes mellitus (DM) is cosmopolitan disease
of the globe. DM is a group of metabolic disorders
characterized by hyperglycemia either due to the lack of
insulin secretion, or defects of insulin action or both. [1]
36 International Journal of Contemporary Medicine, January-June 2021, Vol.9, No. 1
Recent reports showed that there were 171 million
people in the world with diabetes in year 2000 and this
is expected to increase to 366 million by 2030. [2] It is
associated with reduced life expectancy, significant
morbidity due to specific diabetes related microvascular
complications, increased risk of macrovascular
complications (ischemic heart disease, stroke and
peripheral vascular disease), and lessened quality of life.
Glycated hemoglobin (HbA1c) is usually used as a
monitoring tool for measuring glycemic control in DM
patients. It gives glycemic control status for last 120
days. [3] HbA1c predicts risk for development of diabetic
complication in diabetic patients. United Kingdom
Prospective Diabetes Study (UKPDS) has revealed that
risk of diabetic complications was strongly associated
with previous hyperglycemia. Good glycemic control
with decreased level of HbA1c is likely to reduce risk
of complications. [4] Estimated risk of cardiovascular
disease (CVD) has shown to be increased by 18% for
each 1% increase in absolute HbA1c value in diabetics.
[5]
The chronic hyperglycemia can damage several
body organs due to microvascular and macrovascular
complications. [6,7]
Macrovascular complications of diabetes
include cardiovascular disease (CVD) such as
stroke, which is the cause of death in 50% of
diabetics. 8,9On the other hand, microvascular
complications of diabetes include diabetic
nephropathy, neuropathy, and retinopathy. [10]
Cardiovascular risk of diabetes increases further
if diabetes is related with dyslipidemia. However,
this risk can be reduced by good management and
control of both hyperglycemia and dyslipidemia.
[11,12]
Dyslipidemia is one of the major risk factors for
cardiovascular disease in diabetes mellitus Type2. [13-14]
It is estimated that currently India has 62.4 million
people with diabetes mellitus. This is a major public
health challenge, and it is increasing in epidemic
proportions. Chronic hyperglycemia leads to micro-and
macro-vascular complications. The lipid abnormalities
in diabetics such as increased cholesterol, increased
LDH, high triglycerides (TG), and low high-density
lipoprotein (HDL) are contributing to the mortality and
morbidity. Worsening of glycemic control deteriorates
lipid and lipoprotein abnormalities and particularly of
diabetes mellitus. The combination of hyperglycemia,
dyslipidemia, and hypertension produces enhanced
atherogenic environment within the circulation. This
leads to increased risk of ischemic heart disease,
stroke, and myocardial infarction. Diabetes mellitus
is considered as coronary heart disease equivalent.
Insulin resistance, relative insulin deficiency, and
obesity are associated with deranged lipid profile. The
American Diabetes study has come to a conclusion that
HBA1C<7mg/dl signifies optimal blood glucose levels.
The management should focus on controlling diabetes
and managing lipid levels which will reduce mortality
and morbidity for ischemic heart disease and other
diabetic complications. [14-22]
HBA1C is routinely measured to check the
glycemic control over a preceding 8-12 weeks of time. It
is used as an indicator for the state of glycemic control.
Progression of the disease and the development of the
complications in diabetic patients. The aim of the study
was to examine the impact of the glycemic control on
the lipid profile of Type 2 diabetic patients and to know
the importance of HBA1C as an indirect indicator of
dyslipidemia.
Materials and Methods
Study site- Department of Biochemistry and
General Medicine, Katihar Medical College and
Hospital, Katihar, Bihar.
Study duration-This study was carried out on
diabetic patients during one-year period from October
2016 to September 2017.
Source of the data-History, physical examination,
laboratory investigations were obtained from the
medical records department.
Study design-Retrospective, cross-sectional and
descriptive study
Method of collection of data-Total of 200 patient’s
records were accessed from the medical records
department.
Inclusion Criteria: All diagnosed cases of Type 2
diabetes mellitus.
 International Journal of Contemporary Medicine- January-June 2021, Vol 9, No.1 37

Exclusion Criteria: • Stroke

• Age below 18 years The lipid profile of the study was analyzed
according to the ATPIII classification for identification
• Type 1 diabetics
of dyslipidemia, Low HDL <40 mg/dl. High low-density
• Patients on lipid lowering agents lipoprotein (LDL)>190mg/dl, high cholesterol >200
mg/dl, and high TG >200 mg/dl.
• Acute coronary syndrome

Results
Table 1: Demographic data of diabetes mellitus (n-200)

Male 104

Female 96

Mean age of year 62.91

Age range (year) 30-85

Table2: Lipid profile and HBA1C of diabetic patients

Parameter Mean ± SD

Total cholesterol 149.73±47.37

TG 173.27±53.61

LDL 65.86±54.27

HDL 38.61±15.45

HBA1C 8.92±2.24

TG: Triglyceride, LDL: Low‑density lipoprotein, HDL: High‑density lipoprotein, HBA1C

Table3: Frequency of abnormal lipid profile status in all patients

Dyslipidemia Total Male Female

Hypercholestrolemia 72 34 38

Hypertriglyceridemia 64 28 36

low HDL-C 120 66 54

high LDL-C 16 6 10

No abnormal lipid profile 32 18 12

One abnormal lipid profile 90 40 50

Two abnormal lipid profile 56 28 28

>Two abnormal lipid profile 22 8 14

LDL‑C: Low‑density lipoprotein cholesterol, HDL‑C: High‑density lipoprotein cholesterol

38 International Journal of Contemporary Medicine, January-June 2021, Vol.9, No. 1

Figure 1: Sex distribution among study population

Figure 2: Age distribution among the study population

 International Journal of Contemporary Medicine- January-June 2021, Vol 9, No.1 39

Figure 3: Lipid profile among diabetic patients

Figure 4: Correlation ship between glycated hemoglobin and dyslipidemia

A total of 200 patients with Type2 diabetes mellitus
were followed (104males and 96 females) (Figure1). The
mean age was 62.91years with age range of 30-85years
(Table1). Poor glycemic control (HBA1C >8) was seen
in 124 (62%) of total patients. Poor glycemic control
was associated with dyslipidemia in 83( 41.5%) of
total patients, whereas 41( 20.5%) accounted for poor
glycemic control without dyslipidemia, the maximum
frequency of abnormal lipid profile status in all patients
was low LDL cholesterol (LDL-C) (Tables2 and3)
and the age group with maximum patients with both
dyslipidemia and higher HBA1C levels was 51-60 years.
40 International Journal of Contemporary Medicine, January-June 2021, Vol.9, No. 1
Discussion
This study was conducted on randomly selected
200 patients in a Govt. Medical College, Bettiah,
Bihar, India. The lipid profile, fasting blood glucose
(FBG), and HBA1C were investigated. This study
reveals a high prevalence of hypercholesterolemia,
hypertriglyceridemia, high LDL and low HDL levels
which are well known risk factors for cardiovascular
disease and incidence of poor glycemic control in Type 2
diabetic patients. Insulin affects the liver Apo-lipoprotein
production. It regulates the enzymatic activity of
lipoprotein lipase and cholesterol ester transfer protein.
All these factors are likely cause of dyslipidemia in
diabetes mellitus. [23] Worse glycemic control with
dyslipidemia was seen maximum in the individual of
the age group 51-60 years (Figure 2). The core of this
study revolved around identification of an association
between dyslipidemia and poor glycemic control. The
percentage of dyslipidemia individuals among the
study population amounted to 62%, among which
41.5% accounted for dyslipidemia with poor glycemic
control (HBA1C>8mg/dl), thus showing a positive
correlation between dyslipidemia and HBA1C among
patients in the population under study (Figure4). The
pattern of dyslipidemia showed that 84% of the patients
with abnormal lipid profiles and 16% of patients has no
lipid profile abnormality; one lipid profile abnormality
was seen in 45% of the study population,28% had two
lipid profile abnormalities,and11% of the individuals
had more than two abnormal lipid profile parameters.
84% among the study group of 100 patients had lipid
profile abnormalities, among these 36 patients had
hypercholesterolemia, 32% had hypertriglyceridemia,
8% had high LDL-C, and 60% had low HDL cholesterol
levels (Figure3). Lipid abnormalities were more
significant in women study patients in comparison
with those of the male study patients (Figure3). The
significant correlation between HBA1C and FBG is in
accordance with various previous study done all over the
world. Higher levels of FBG were noted in patients with
poor glycemic control (84% of total study population of
Type 2 diabetics). [23]
Conclusion
Association between lipid profile and HBA1C was
evident in this study. Achieving the target in HBA1C
will contribute in improving the lipid state, and hence
may lessen the diabetic complications in Type 2 diabetic
patients. Thus, by maintaining a good glycemic control,
risk for the development of dyslipidemia and cardiac
diseases can be reduced. Further studies should be
conducted on a larger scale to significantly explore the
role of HbA1c in the development of dyslipidemia in
type-2 Diabetic patients.
Source of Support: Self
Conflict of Interest: Nil
Ethical Clearance: Taken from K.M.C.H. Katihar,
Bihar
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