RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCESBENGALURE, KARNATAKA

PROFORMA FOR REGISTRATION OFSUBJECTS FOR DISSERTATION

1.

NAME OF THE CANDIDATE AND ADDRESS

MISS. C. VIRONICA

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.”

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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

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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

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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

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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

4

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

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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

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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.

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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

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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

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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

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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

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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

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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.

6.3.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

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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.

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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.

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7.2.7 Sample size:

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

Bengaluru.

7.2.8 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.

7.2.10 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

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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.

7.4 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.

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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 http://www.sinornedresearch.org/alcoholichep/intro.htm… 15K

5. Johns Hopkins Medicine Gastroenterology & Hepatology.

Available from http://www.hopkins-gi.org/GDL.Disease.aspx?currentUDV=31&

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 http://pubs.niaaa.nib.gov/publications/arh27-1/95-109.htm

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

Available from http://www.bnj.com/content/340/bmj.c1240.full.

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

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11. W. Liang, T. Chikritzhs, R. Pascal, C.W. Binns. Diagnosis of alcoholic liver

disease. 1993. Internasl medicine journal. Available from

http://ndri.curtin.edu.au/local/docs/pdf/ublications/RJ740.pdf

12. Lelbach. Liver function test and alcohol intake.

Available from http://pubs.niaaa.nih.gov/publications/arh27-3/209.219.

13. Professor Chistopher P. 18 march2011. Available from

http://www.nc.ac.uk/biomedicine/researchgroups/profile/chr

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

http://www.robinroom.net/effects.doc

15. Professor Chistopher P. Day 2008

Available from http://www.nc.ac.uk/biomedicine/researchgroups/profile/chr

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

Available from http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0676.1988.

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

Available from http://www.ncbi.n/m.nih.gov/pmc/articles/pmc2916935

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

Available from http://onlinelibrary.wiley.com/doi/10.1002/hep.1840200611/pdf

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

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Available from www.ncbi.nlm.nih.gov/pubmed/1343377

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

from URL:www.medscape.com/viewarticle/739272.

24.Sarmistha Biswas, Sujat Paul Vol12, Vol(2011) Available from

www.banglajol.into/index.php/jom/article/view/6925.

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

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

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

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9 SIGNATURE OF THE CANDIDATE

10REMARK 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

GUIDE.

A. SIGNATURE

B. CO-GUIDE

C. SIGNATURE

D. HEAD OF THE

DEPARTMENT

E. SIGNATURE

MRS.ROOPA SARITHA REDDY.

ASSOCIATE PROFESSOR,

DEPARTMENT OF MEDICAL

SURGICAL NURSING,

K R COLLEGE OF NURSING,

BANGALORE.

MRS. ROOPA SARITHA REDDY

12 REMARKS OF THE PRINCIPAL

21

SIGNATURE

22