Introduction : - Alcohol related liver disease is a major ...



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BENGALURE, KARNATAKA

PROFORMA FOR REGISTRATION OF

SUBJECTS FOR DISSERTATION

|1. | |MISS. C. VIRONICA |

| | | |

| |NAME OF THE CANDIDATE AND ADDRESS |K.R. COLLEGE OF NURSING, |

| | | |

| | |#59,25/4/74 KATHA NO.1935,C & M |

| | | |

| | |COMLEX,OMKAR LAYOUT, |

| | | |

| | |UTTARAHALLI–KENGERI MAIN |

| | | |

| | |ROAD, BANGALORE-60. |

|2. |NAME OF THE INSTITUTION |K.R. COLLEGE OF NURSING |

|3. |COURSE STUDY AND SUBJECT | M.Sc.NURSING, MEDICAL SURGICAL NURSING |

|4. |DATE OFADMISSION OF COURSE |07-06-2011 |

|5. |TITLE OF THE TOPIC |“A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED |

| | |TEACHING PROGRAMME ON ALCOHOLIC LIVER DISEASE AMONG MEN IN TERMS |

| | |OF KNOWLEDGE BETWEEN AGE GROUP OF 25-55 YEARS AT SELECTED RURAL |

| | |AREA,BENGALURU.” |

6. A BRIEF RESUME OF THE INTENDED WORK

“First the man takes a drink; then the drink takes a drink; then the drink takes the man”

Japanese Proverb

INTRODUCTION

Alcohol is an organic compound in which the hydroxyl functional group is bound to a carbon atom .An important class of alcohols are the simple acyclic alcohols, ethanol is the type of alcohol found in alcoholic beverages and in common speech the word alcohol refers specifically to ethanol. Ethanol has been produced and consumed by humans for millennia, in the form of fermented and distilled alcoholic beverages. Alcoholism, also known as Alcohol Addiction, is a broad term for problems with alcohol, and is generally used to mean compulsive and uncontrolled consumption of alcoholic beverages, usually to the determine of people suffering from alcoholism are often called "alcoholics". The World Health Organization estimates that there are 140 million people with alcoholism worldwide. Alcoholism is called a "dual disease" since it includes both mental and physical components. The biological mechanisms that cause alcoholism are not well understood. Social environment, stress, mental health, family history, age, ethnic group and male, all influence the risk for the condition.1

Alcohol related liver disease is a major cause of morbidity and mortality rate. Alcoholic liver disease encompasses a clinic histological spectrum, including fatty liver, alcoholic hepatitis, and alcoholic cirrhosis. Fatty liver is a benign and reversible condition

but progression to alcoholic hepatitis and cirrhosis is life threatening. Alcoholic hepatitis is diagnosed predominantly on clinical history, physical examination, and laboratory

1

testing, although liver biopsy is often necessary to secure the diagnosis.2

The major focus of management is abstinence from alcohol, supportive care, treatment of complications of infection, portal hypertension and maintenance of positive nitrogen balance through nutritional support. Corticosteroid therapy is controversial but should be considered in patients with a discriminant function greater than 32 and/ or presence of spontaneous hepatic encephalopathy in the absence of infection, gastrointestinal bleeding, and renal failure.3

The only curative therapy for advanced alcoholic cirrhosis is liver transplantation. Several recent advances in understanding the pathogenesis of alcoholic liver disease may lead to novel future treatment approaches, including inhibition of tumor necrosis factor, antioxidant therapy, stimulation of liver regeneration and stimulation of collagen degradation.4

According to a prospective analysis on profile of Alcoholic liver disease in an Indian hospital, the percentage of adults with 18 years of age and over who were current regular drinkers were 52 percent, the percentage of adults and were current infrequent drinkers were 13 percent, the number of alcoholic liver disease deaths were 14,406 and the number of Alcoholic liver disease deaths, excluding accidents and homicides were 23,199.5

The prevalence of alcoholic liver disease is influenced by many factors, including genetic factors (eg. Prediction to alcohol abuse, sex) and environmental factors (eg. availability of alcohol, social acceptability of alcohol use, concomitant hepatotoxic insults) and it is therefore difficult to define. In general, however, the risk of liver disease increases with the quantity and duration of alcohol intake. One in five heavy drinkers

develops alcoholic hepatitis, and one in four develops cirrhosis.6

Different alcoholic beverages contain varying quantities of alcohol. Although fatty liver is a universal finding among heavy drinkers, unto 40 percent of those with modest alcohol intake (≤10g/day) also exhibits fatty changes. Based on an autopsy series of men, a threshold daily alcohol intake of 40g is necessary to produce pathologic changes of alcohol hepatitis but not in the overall prevalence and there is a clear close dependent relation between alcohol intake and the incidence of alcoholic cirrhosis. A daily intake of more than 60g of alcohol in men and 20g in women significantly increases the risk of cirrhosis. 7

The diagnosis of alcohol induced liver disease was observed in 13,285 men and women (aged 29-30 years) An estimated relative risk of developing liver disease was determined at an intake of 1-6 alcoholic beverages per week, with a steep increase in risk above this intake. Men were found to have a significantly higher relative risk of developing alcohol related liver disease than women. At 7-13 percent alcoholic beverages per week for women, and 14-27 percent for men and there is a relative risk of developing liver disease was greater in men than women.8

Although alcohol consumption has existed in India for many centuries, the quantity, patterns of use and resultant problems have undergone substantial changes over the past 20 years. These developments have raised concerns about the public health and

social consequences of excessive drinking.9

6.1 NEED FOR THE STUDY

Alcoholic liver disease is a major source of alcohol related morbidity and mortality. Heavy drinkers and alcoholics may progress from fatty liver to alcoholic hepatitis to cirrhosis, and it is estimated that 10 percent to 15 percent of alcoholics will develop cirrhosis. The likelihood of developing alcoholic liver disease is to a large extent, a function of both the duration and amount of heavy drinking, and the per capita consumption of alcohol within populations has been shown to be a strong determinant of cirrhosis mortality rates. Recent studies also suggest that alcohol and hepatitis c may exert a multiplicative effect on risk for cirrhosis and other liver disease. To date, the evidence indicates that increases in participation in alcohol anonymous and other treatment for alcohol abuse have played an important role in reducing cirrhosis mortality rates.10

Other research suggested that cirrhosis mortality rates may be more closely related to consumption of certain alcoholic beverages specifically spirits than to total alcohol consumption, and that beverage specific effects can account for the fact that cirrhosis rates appeared to decrease although consumption rates were increasing in the 1970’s. Important differences in Alcoholic liver disease rates in men and women and as

well. Indian made foreign liquors such as whisky, rum, vodka and gin (42.8percentage) and illicitly distilled spirits (in determinate composition) constitute more than 95 percentages of the beverages consumed by both men and women. Prevalence among women has consistently been estimated less than 5 percent (3-5) but is much higher in the north eastern states. 10

A study was conducted on 319 patients in an alcoholism clinic in Germany with an aim to calculate the average amount of alcohol consumed in 24 hours per day. As those who did not have cirrhosis but did have other liver malfunctions had intermediate rates of alcoholic intake. In addition, patients with normal liver function had been drinking heavily for only about 8 years on average, whereas those with cirrhosis had been drinking heavily for more than 17 years on average. This study concluded that, the risk of developing cirrhosis is a function of both quantity and duration of alcohol consumption. 11

National Institute on Alcohol Abuse and Alcoholism surveyed a group of 4,422 adults meeting the criteria for alcohol dependence and found that after one year, some met the authors' criteria for low-risk drinking, even though only 25.5 percent of the group received any treatment, with the breakdown as follows, 25 percent were found to be still dependent, 27.3 percent were in partial remission (some symptoms persist), 11.8 percent asymptomatic drinkers (consumption increases chances of relapse) and 35.9 percent were fully recovered made up of 17.7 percent low-risk drinkers plus 18.2 percent abstainers. The prevalence of current use of alcohol ranged from a low of 7 percent in the western state of Gujarat to 75 percent in north eastern state of Arunachal Pradesh.12

Most of the people in U.K drink alcohol. Total alcohol consumption per head in the UK rose steeply between 1950 and 1975 and then leveled off until the mid 1990’s when it again stated to climb. The general lifestyle surveys of 2008 found that 38 percent of men and 29 percent of women were likely to have exceeded the recommended daily maximum (4 units for men and 3 for women) in the week proceeding in tree view. 13

A study was conducted by an international group of scientists sponsored by the world Health organization. The resulting book “Alcohol control policies in public health perspective” reviewed studies of clinical and non clinical populations of heavy drinkers. All studies found that a greater proportion of heavy drinkers died of cirrhosis than would be expected based on rates of cirrhosis deaths among heavy drinkers ranged from 2 to 23 times higher than the rate that would be expected in the general population. The study concluded that there is a greater effect of alcohol consumption on cirrhosis and other forms of alcoholic liver disease.14

In the last 10 years, the proportion of men and woman drinking alcohol is more than 21 units weekly (28 percent for men and 15 percent for women). A unit of alcohol is a single measure of spirits, a half pint of ordinary beer or larger or a standard size glass of wine. These rates have increased alarmingly in recent years. Death rates from alcoholic liver disease in the UK rose by from 3,236 in 2002 to 4,400 in 2008.

Alcohol related data remain scarce in India and so far there have been very few scientific studies. With the above incidence, review, prevalence & mortality rates of alcoholic liver disease, the researcher felt the need to assess the effectiveness of structured teaching program on alcoholic liver disease for men in rural settings as it is evident that men are addicted to alcohol consumption especially in rural settings and structured teaching program would be of great benefit to decrease the risk of alcoholic liver disease.15

6.2 REVIEW OF LITERATURE

Review of literature is a systematic identification, location scrutiny and summary of written material that contain information on research problems.

The review of literature related to the topic are organized and presented under the following headings.

1. Review literature related to incidence of Alcoholic liver disease.

2. Review Literature Related to knowledge of men regarding Alcoholic Liver Disease

3. Review of literature related to structured teaching program.

1. Review literature related to incidence of Alcoholic liver disease.

A study was conducted regarding profile of alcoholic liver disease in an Indian hospital, the samples selected for the study were 144 males patient on the basis of their histological findings. The amount of alcohol consumed by patients with AFL, AH and AC was not significantly different. Similarly, the duration of alcohol consumption was not significantly different between these groups of patients. The clinical features of the patients were quite similar to these reported from the west, expect that AH was relatively milder in some patients. The study concluded that intake of poor quality country liquor was quite common (60 percent), but its use was not found to be associated with more severe liver injury as compared with the use of good quality foreign varieties of liquor.16

A study was conducted regarding Alcoholic liver disease related mortality in the united states with an aim to underestimate the mortality attitude to alcoholic liver disease in previous investigations and shifting attention to hepatitis C. virus related mortality.

The data was compiled from the National Vital Statistics system from 1980-2003 using categorization by both international classification of disease (ICD)-9 and ICD-10 systems. A total of 2, 87,365 deaths were observed over the 24 periods. Age specific mortality related to Alcoholic liver disease was highest in the ages of 45-64 years. The study concluded that the proportion of alcohol related liver disease deaths is still considerably large and comparable in scope to that of Hepatitis virus.17

A study was conducted on prevalence of chronic liver disease is an Italian cohort. In this 6,534 subjects aged 12-65 were fully examined, and their alcohol intake evaluated with a dietary questionnaire. The risk threshold for developing liver damage was found at ingestion of more than 30gms alcohol/ day by both men and women. 21 percent of the study groups were at risk, and 5.5percentage of this risk group showed signs of liver damage. Alcoholic cirrhosis was diagnosed in 2.2 percentage of the risk group and non-cirrhosis liver disease in 3.3percentage.The study concluded that in an open population the risk threshold for developing cirrhosis and non-cirrhosis liver damage is 30gms ethanol per day. 18

A study was conducted to estimate the prevalence of nonalcoholic fatty liver disease in general population. History, clinical examination, anthropometric measurements, biochemical tests and abdominal ultrasound were evaluated in railway colonies. The participants were 1,168 and persons with any alcohol consumption, HBS Ag positive, Anti HCV positive, persons with other known liver disease and taking medications causing liver disease was excluded. The study concluded that prevalence of nonalcoholic fatty liver disease was high in males than in females and males who are at

risk of nonalcoholic fatty liver disease will be more than 40 years of age.19

A study was conducted with an aim to examine the relationship of daily alcohol intake, types of alcoholic beverage consumed, and drinking patterns to the presence of alcoholic induced liver damage in an open population. The researches selected 6534 subjects and each subject underwent medical history and physical examination and data were obtained from dietary questionnaires .The prevalence of pure alcoholic cirrhosis was 0.43percentage representing 2.2percentage of the individuals at risk with a ratio of men to women of 9:2. After 50 years of age, the cumulative risk of developing cirrhosis was significantly higher for those individuals who regularly drunk alcohol both with and without food than for those who drank only at meal times. The study concluded that the risk threshold for developing cirrhosis is increasing with daily intake. 20

A study was conducted regarding epidemiological and clinical aspects of liver cirrhosis with the aim to evaluate the incidence, outcome and complications of liver cirrhosis in a Swedish population and in Ireland. The annual incidence of liver cirrhosis in Gothenburg was 15.3 ± 2.4/ 100.000 compared to 3.3± 1.2/ 100.000 in Iceland. In Gothenburg 50 percentage of the patients had alcoholic cirrhosis compared to 29 percentages in Ireland. Causes of death due to liver failure were 26 percentage. Patients with liver cirrhosis had 267 times increased risk of hepatocellular cancer. Among patients with HCV cirrhosis, 19 percentage developed HCC and 20 percentage of those with HCV and alcoholic liver disease. The study concluded that the incidence of liver

cirrhosis is low in Iceland with few complications. 21

2. Review Literature Related to knowledge of men regarding Alcoholic Liver Disease

A study was conducted regarding Alcoholic Liver Disease related controlled trial on the use of Silymarin in patients with alcoholic liver disease two patients were admitted to the trial and randomly assigned to an experimental or controls group. Experimental group received 280mg/ day of Silymarin and controls an equal number of placebo tablets. 34 patients received placebo and 25 patients received the drug. Both groups had a positive urine sample analysis for alcohol during follow up. Those who abstained from alcohol had a significant fall in gamma glutamic transferace during follow up. No other significant differences were observed between these two groups. The study concluded that in this trial, Silymarin did not change the evolution or mortality of alcoholic liver disease. 22

A study was conducted regarding Alcoholic Liver Disease in tribal alcoholics of Chittagong hill tracts of Bangladesh. In the Hill tracts, there is no social stigma in taking alcohol. Relatively little is known about this aspect in Bangladesh. This small-scale study was done to identify the spectrum of liver disease among tribal people. Subjects were included from both the urban and rural area of different socioeconomic classes. History, meticulous clinical examination and investigations were done to detect the pattern of alcohol induced liver injury. Among the 50 cases, 47 patients were male and 3 were female cases. Both regular and irregular drinkers were included. Alcohol induced liver damage was noticed only in 17 cases. Nearly two-thirds of the participants were free from any form of liver disease. The study concluded that the presence of risk factors

for developing alcoholic liver disease, the prevalence was found to be low among the tribal alcoholic participants in this study.23

A study was conducted alcoholic liver disease related on the association between alcohol use and the risk of tuberculosis. This identified 3 cohort and 18 case control studies. The pooled relative risk across all studies that used an exposure cut-off level set at 40 g alcohol per day or above, or defined exposure as a clinical diagnosis of an alcohol use disorder, was 3.50 (95 percent). After exclusion of small studies, because of suspected publication bias, the pooled relative risk was 2.94 (95 percent).The risk of active tuberculosis is substantially elevated in people who drink more than 40 g alcohol per day, and/or have an alcohol use disorder. This may be due to both increased risk of infection related to specific social mixing patterns associated with alcohol use, as well as influence on the immune system of alcohol itself and of alcohol related conditions.The study concluded that there is an association between alcohol use and risk of tuberculosis.24

3. Review of literature related to structured teaching program

A structured teaching and self-management program was conducted to investigate the effects of patients’ self-management of oral anticoagulation therapy on accuracy of control and measures of treatment-related quality of life. A total of 179 patients receiving long-term oral anticoagulation treatment were enrolled at 5 referral centers in Germany. Patients were randomized to an oral anticoagulation self-management group based on a structured treatment and teaching program and international normalized ratio self-monitoring. The control group received conventional care as provided by family physicians, including referral to specialists if necessary. Treatment-related quality-of-life measures, especially treatment satisfaction scores, were significantly higher in the intervention group compared with controls. The study concluded that an anticoagulation education program that includes self-management of anticoagulation therapy results in improved accuracy of anticoagulation control and in treatment-related quality-of-life

measures. 25

A study was conducted to perform a cost-effectiveness analysis of the structured treatment and teaching program for patients with alcoholic liver disease at Dusseldorf University. They investigated whether the monetary benefits outweighed the costs of the intervention. Adult patients with moderate to severe alcoholic liver disease participated in a 5 day in-patient program. Compared to the year before the program, days spent in hospital were 5.2 days per patient per year, days of absence from work were 18.4 days per patient per year, acute severe alcoholic liver disease attacks were 3.8 attacks per patient per year, and physician consultations were 2.3 visits per patient per month. The program produced net benefits within 3 yrs. The study concluded that the intervention produced net monetary benefits and the program deserves implementation, not only for its demonstrated medical benefits but also for its economic saving.26

PROBLEM STATEMENT

A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON ALCOHOLIC LIVER DISEASE AMONG MEN IN TERMS OF KNOWLEDGE BETWEEN AGE GROUP 25-55 YEARS AT SELECTED RURAL AREA, BENGALURU.

3. .OBJECTIVES:

• To assess the existing knowledge of men regarding alcoholic liver disease by pretest knowledge scores.

• To administer structured teaching programme regarding alcoholic liver disease.

• To assess the knowledge of men regarding alcoholic liver disease by posttest

knowledge scores.

• To determine the effectiveness of structured teaching programme by comparing pretest and posttest knowledge scores.

• To find out the association between pretest knowledge scores of men with the selected demographic variables.

6.4. OPERATIONAL DEFINITIONS

• ASSESS:- To determine the knowledge scores of men regarding Alcoholic Liver Disease.

• EFFECTIVENESS:- It refer to significant gain is knowledge as determined by significant difference in pre and post test knowledge scores.

• STRUCTURED TEACHING PROGRAM:-

Refers to the systematically developed instructional method and teaching aids

designed for men to provide information regarding Alcoholic liver disease.

• KNOWLEDGE:-It refers to correct written responses provided by men regarding alcoholic liver disease according to the close ended questionnaire.

• ALCOHOLIC LIVER DISEASE:- It refers to the clinical condition caused by chronic excess of alcohol consumption, including alcoholic cirrhosis and alcoholic fatty liver

• MEN:- Men between age group of 25 to 55 years residing in rural areas of Bengaluru.

• SELECTED RURAL AREAS:- Kumbalgudu rural area near Kengeri, Bengaluru.

6.5. ASSUMPTIONS:-

• Men may have inadequate knowledge regarding alcoholic liver disease.

• Structured teaching program may enhance knowledge in men regarding alcoholic liver disease.

6.6. RESEARCH HYPOTHESIS

• H1-There will be significant difference between pretest and posttest knowledge scores regarding alcoholic liver disease

• H2-There will be significant association between pretest knowledge scores with the selected demographic variables.

6.7. VARIABLES UNDER STUDY

DEPENDENT VARIABLE:-

Knowledge of men regarding Alcoholic liver disease.

INDEPENDENT VARIABLE:-

Structured teaching program regarding Alcoholic liver disease.

DEMOGRAPHIC VARIABLES:- Age, Sex, Education, Occupation, religion,type of family, family income and exposure to mass media.

7. MATERIALS AND METHODS:-

7.1 SOURCE OF DATA: -

Data will be obtained from men residing in selected rural areas of Bengaluru.

7.2 METHOD OF DATA COLLECTION

7.2.1 Research approach:

Evaluative approach is used for the present study.

7.2.2 Research design:

A Quasi Experimental one group pretest and posttest design is used for the study.

7.2.3 Research settings:

The proposed study will be conducted in selected rural areas of Bengaluru.

7.2.4 Population:

Men between age group of 25-55 years residing in selected rural areas of Bengaluru.

7.2.5 Sample:

Men in selected rural areas of Bengaluru.

7.2.6 Sampling technique:

The sample technique for my study is non-probabilit Convenient sampling technique.

7.2.7 Sample size:

Total sample size of the study will consists of 40 men residing in selected rural areas of Bengaluru.

8. Sampling criteria

Inclusion criteria:

• Men between age group of 25-55 years.

• Who are willing to participate in the study.

• Who are available at the time of data collection.

Exclusion criteria:

• Men who are not willing to participate in the study.

• Men below age group of 25 years and above 55years.

Duration of study:

The study will be conducted for the period of 2 months.

7.2.9 Tools of data collection:

Structured knowledge questionnaire used to collect the data. It consist of two parts

PART A: Items on demographic variables like age, sex education, occupation, religion, type of family, family income and exposure to mass media

PART B: Knowledge questionnaire regarding alcoholic liver disease.

10. Data collection procedure:

Formal permission will be obtained from the head of the village to conduct the study. The researcher introduces herself to the participate in the study. Structured Interview will

be conducted to the participants. The time duration for each participant will be 30-40 minutes. Structured teaching program will be given to the participants on the next day and on the 7th, day Structured Interview will be conducted.

7.2.11 Method of data analysis:

Descriptive Statistics:-

The obtained data will be calculated by mean, mode, median and standard deviation.

Inferential Statistics:-

• Paired t-test will be used to find out the significant difference between pre and post test knowledge scores of men regarding alcoholic liver disease.

• Chi-Square test will used to determine the association between the pre test knowledge scores of men regarding alcoholic liver disease with the selected demographic variables.

7.3 Does the study require any investigation or interventions to be conducted on patients or other human or animals?

Yes, only educational intervention will be conducted on men regarding alcoholic liver disease.

4. Has ethical clearance been obtained from your institution?

• Ethical clearance will be obtained from research committee of K.R. College of Nursing, Bengaluru.

• Written permission will be taken from the head of the Village.

• Informed consent will be taken from men residing in selected rural areas of Bengaluru.

8. REFERENCE : -

1. Joyce. M. Black, Jane hokanson Hawks. Mastering Medical Surgical Nursing. Medical Surgical Nursing. clinical management of positive outcomes. 7th ed. Volume-1. p. 1336-1352.

2. Brunner and Suddharth. Textbook book of Medical Surgical Nursing. 6th ed. p. 1159-1160, 2170-2175.

3. Lewis Heitkemper. Medical Surgical Nursing. Assesment and management of clinical problems. 7th ed. p. 1101-1116.

4. Dr. Zhang. Alcoholic Liver Disease.

Available from … 15K

5. Johns Hopkins Medicine Gastroenterology & Hepatology.

Available from GDL.

6. Anand. B. S. Ciorhosis of the liver western journal of medicine. p. 171:110-115.1999.

7. V. Savolainen et al Alcohol clin exp Res (1993) 17 (5).

8. Kim Bloomfield, Dr. PH. International Comparisons of alcohol consumption. Available from

9. Carole L Hart, cohort studies of risk on both men & women. 11 March 2011.

Available from .

10. Shekhar Saxena,country profile on alcohol in India 2011 PDF 3

11. W. Liang, T. Chikritzhs, R. Pascal, C.W. Binns. Diagnosis of alcoholic liver disease. 1993. Internasl medicine journal. Available from

12. Lelbach. Liver function test and alcohol intake.

Available from .

13. Professor Chistopher P. 18 march2011. Available from

14. Bruun et al 1975 study on effects of alcohol controls available from

15. Professor Chistopher P. Day 2008

Available from

16. Wiley online library volume 8, issue 3 10 dec 2008.

Available from .

17. Vijay H. 23 Feb 2011, Alcoholic Liver Disease related mortality in the US.

Available from

18. .Wiley online library Hepatology 12 Dec 2005 volume 20 issue 6.

Available from

19. Clark, Jeanne MMD, MPH Journal of clinical Gastroenterology March 2006 volume 40.issue-pps5.510 doi:10.1097/01.

20. Giorgio Bedogni July 2005 volume 42 issue 1, pages 44-52.

21. Steingerour Anna Gunnarsdothir. Department of internal medicine.Rev Med Chil. 1992 Dec; 120(12):1370-5.

22. Bunout D, Hirschs. 1992 Dec;120(12)L1370-5

Available from ncbi.nlm.pubmed/1343377

23. Thomas .H. Frazier, MD;Abigail M.Gastroenterology 2011;4(1):63-81.Available from URL:viewarticle/739272.

24.Sarmistha Biswas, Sujat Paul Vol12, Vol(2011) Available from banglajol.into/index.php/jom/article/view/6925.

25. C Trantnes, B Richtee and M. Berger nov 1, 1999

Available from nhlbi.health/prof/lung/asthmal ast.cost.pdf

26 .JAMA 1999; 281(2);145-150 doi.10,1001/jama.281.2.145

|9 |SIGNATURE OF THE CANDIDATE | |

|10 |REMARK OF THE GUIDE |THIS STUDY IS ATTEMPT TO IMPROVE THE KNOWLEDGE OF MEN |

| | |REGARDING ALCOHOLIC LIVER DISEASE .THE STUDY IS RELEVANT TO |

| | |THE PRESENT SENARIO MAY BE APPROVED. |

|11 |NAME AND THE DESIGNATION OF | MRS.ROOPA SARITHA REDDY. |

| |GUIDE. |ASSOCIATE PROFESSOR, DEPARTMENT OF MEDICAL SURGICAL NURSING,|

| | | |

| | |K R COLLEGE OF NURSING, BANGALORE. |

| | | |

| | | |

| |SIGNATURE | |

| | | |

| |CO-GUIDE | |

| | |MRS. ROOPA SARITHA REDDY |

| |SIGNATURE | |

| | | |

| |HEAD OF THE DEPARTMENT | |

| | | |

| |E. SIGNATURE | |

|12 |REMARKS OF THE PRINCIPAL | |

| | | |

| |SIGNATURE | |

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