B.L.D.

E UNIVERSITY BIJAPUR, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION TITLE OF THE TOPIC A STUDY OF DISTRIBUTION OF ABO BLOOD GROUPS AMONG PATIENTS WITH DIABETES MELLITUS AND THEIR SECRETOR STATUS

DR. MUDDASER MUJAWAR PG IN MEDICAL PHYSIOLOGY (M.Sc MEDICAL PHYSIOLOGY) UNDER THE GUIDANCE DR.MANJUNATHA. AITHALA. PROFESSOR AND HEAD OF DEPARTMENT OF PHYSIOLOGY B.L.D.E.US SHRI B.M.PATIL MEDICAL COLLEGE BIJAPUR-586103

B.L.D.E.UNIVERSITY SHRI B.M.PATIL MEDICAL COLLEGE BIJAPUR 1. NAME OF THE CANDIDATE AND ADDRESS DR.MUDDASER MUJAWAR DEPARTMENT OF PHYSIOLOGY

B.L.D.E.US SHRI B.M.PATIL MEDICAL COLLEGE HOSPITAL AND RESEARCH CENTRE, BIJAPUR-586103 2. NAME OF THE INSTITUTE B.L.D.E.US SHRI B.M.PATIL MEDICAL COLLEGE HOSPITAL AND RESEARCH CENTRE, BIJAPUR-586103 3. COURSE OF THE STUDY AND SUBJECT 4. DATE OF ADMISSION TO THE COURSE. 6. TITLE OF THE TOPIC A STUDY OF DISTRIBUTION OF ABO BLOOD GROUPS AMONG PATIENTS WITH DIABETES MELLITUS AND THEIR SECRETOR STATUS 02-08-2011 3 YEARS, MSc MEDICAL PHYSIOLOGY

7.

BRIEF RESUME OF THE INTENDED WORK. 6.1 NEED FOR THE STUDY 6.2 REVIEW OF LITERATURE 6.3 OBJECTIVES OF STUDY MATERIALS AND METHODS 7.1 SOURCE OF DATA ANNEXURE-II ANNEXURE-I ANNEXURE-I ANNEXURE-I

7.2 METHOD OF COLLECTION OF DATA 7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO BE CONDUCTED ON PATIENTS, ANNEXURE-II ANNEXURE-II

HUMANS OR ANIMALS. IF SO PLEASE DESCRIBE BRIEFLY. 7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION IN CASE OF 7.3 ANNEXURE-II

8.

LIST OF REFERENCES

ANNEXURE-III

9.

SIGNATURE OF THE CANDIDATE

10 REMARKS OF THE GUIDE .

11 NAME AND DESIGNATION . 11.1 GUIDE DR. MANJUNATHA. AITHALA. M.D.PHYSIOLOGY PROFESSOR AND HEAD DEPARTMENT OF PHYSIOLOGY

11.2 SIGNATURE

11.3 HEAD OF THE DEPARTMENT

DR. MANJUNATHA. AITHALA. M.D.(MEDICAL PHYSIOLOGY) PROFESSOR AND HEAD DEPARTMENT OF PHYSIOLOGY

11.4 SIGNATURE

12 12.1 REMARKS OF THE CHAIRMAN . AND PRINCIPAL

12.2 SIGNATURE

ANNEXURE I
6. Brief resume of the intended work

NEED FOR THE STUDY

Interest in the presence of and importance of blood groups had aroused during second half of 19th century because of conclusive association of blood groups and its roles in pathogenesis of erythroblastosis foetalis. So far, more than 20 genetic polymorphism have been shown to be there in the antigens of the red cells and serum proteins. The

agglutinogens in each system are determined by allelic genes occurring at specific loci on the chromosomes.1 Moreover, each system of antigens inherited

independently of other system. The different frequency of occurrence in different racial groups, importance of is

sensitization, the simple

mode of inheritance to serve as

genetic markers and the biochemical properties etc ; all made the study of blood groups as an integral part of serology, anthropology, genetics and as well as biochemistry. 2

ABO blood groups have been co-related with various diseases. Incidence of peptic ulcer is much higher in blood group O, where as cancer of stomach, tumors of salivary glands, and leprosy are more frequent in A group individual. It is

assumed that blood group substances may interact with microbes and makes a person more or less susceptible to a particular disease. Moreover, progressive loss of blood group substances from the tissues cell make them carcinomatous. 3 Further, co-relation between secretor status and diseases of gastrointestinal tract has also been worked out. These blood group substances are also present on leucocytes and seem to affect their property of phagocytosis.
3

Absence of blood group substances in body fluids is a health disadvantage, as this appears to increase susceptibility to number of diseases. The secretion of the antigen into saliva and mucous offers added degree of prediction against bacterial fimbria letins. 4

Earlier studies have indicated that secretor status are more prone to hemolytic anemia, oral cancer and viral infections , where as diseases like tuberculosis, Rheumatic fever, juvenile diabetes and various auto immune diseases are more common in non-secretors. 5

In the genetics of the secretor system two options exist. A person can be either a Secretor (Se) or a Non-secretor (se). This is completely independent of whether an individual is a blood type A, B, AB, or O. This means that someone can be an A Secretor or an A Non-secretor, a B Secretor or a B Non-secretor etc.
6

In a simplified sense, A Secretor is defined as a person who secretes his blood type antigens into body fluids and secretions like the saliva in mouth, the mucus in digestive tract and respiratory cavities, etc. Basically what this means is that a secretor puts his/her blood type into these body fluids. A Non-secretor on the other hand puts little to none of his/her blood type into these same fluids. As a general rule, in the U.S. about 80% of the population are Secretors remaining 20% are Non-secretors. 6 Despite the fact that the association of blood groups with certain diseases is clearly demonstrated, and the evidence that blood groups may play an important role in certain diseases, for example, peptic ulcer and gastric cancer, some other studies report no association between ABO blood group with those diseases, including DM. It is not surprising that the data on association of diabetes with ABO blood groups is scanty and mostly shows no association. However, there is evidence of positive association as well.

In addition, it was found that the A blood group appears with the highest frequency among Malay healthy controls, but in Indians blood group B is the most dominant. In a recent study, it was found that blood group B was prevalent at a high percentage among patients with DM type 2 35.71% in

comparison

to

that

of

controls,

22.52%,

but

there

was

no

statistically significant difference (P>0.05).

So, it was concluded that there is an association between blood groups A and O and DM type 2 and the association is negative as these groups are less common in diabetics and seems to be protective from the disease. Large studies in other ethnic groups are needed to confirm these results. Hence undertaken. the study has been

ANNEXURE I

6.2

Review of Literature:

A study conducted in Bangladesh with a sample size of 2,312 patients and 8,936 controls that there was no association between ABO blood groups and DM. But results show a significantly lower percentage of O and A blood groups among diabetic patients, which means a negative association with these blood groups. A larger sample study will be needed in our population to further investigate this finding. A study carried out in India included 511 patients with DM type 2 in Madhya Pradesh. The samples represented adequately the Brahmin (n=146), Bania (n=127), Kayasth (n=52), Shudra (n=59), and Muslim groups (n=51). In total, 475 unrelated normal healthy individuals were sampled randomly from the same area, matching age, sex, socio-economic status, etc., but not the disease condition. For the ABO blood types, standard serological procedures were followed. Statistical analysis was done using the Chisquare test and the findings suggested that there was no association between the ABO . 7 In 2009, a study was conducted to show interrelationship

between DM type 2 and ABO blood groups. It was found that among 70 patients with DM, blood group B was more common and represented 35.71% compared to that of control, which represented only 22.14% of the sample population, but statistical significance was not achieved. 7

A study was conducted to show the frequencies of blood groups A and B & differences between populations. The observations raised fundamental questions regarding the causes of these differences. From another study it was suggested that P falciparum was in the right position during evolutionary history to affect the

origin and relative proportion of ABO antigens; that the geographic distribution of ABO antigens worldwide is consistent with a survival advantage in malaria among group O individuals;9
10

A study was conducted to determine the frequency of ABO and Rhesus (Rh) blood groups in Pakistan. It was a cross sectional prospective study and was conducted over a period of one year.
8

Out of 22897 subjects 17141 (74.86%) were male subjects and 5756 (25.140%) were female. Out of 17141 male subjects 15597 (90.99%) and out of 5756 female subjects 5040 (87.56%) were found to be Rh-positive. The frequency of Rhnegative group in male subjects were (9.01%) where as in female subjects were (12.22%). The frequency of A, B, O and AB groups in Rh-positive male subjects were 25.63%, 29.54%, 26.04% and 9.78%, amongst female subjects, it was 24.53%, 28.06%, 25.54% and 9.43% respectively. In Rh-negative male subjects the frequency of A, B, O and AB is 2.25%, 2.88%, 3.01% and 0.88%, while amongst females it is 3.54%, 4.24%, 3.74% and 0.92% respectively.
8

It was concluded from this study that frequency of Rhpositive blood group was B, O, A, and AB in both gender, where as the most common Rh-negative in male and female subjects are O, B, A, AB, and B, O, A, and AB respectively.8

A study was conducted in Non-O blood groups subjects and demonstrated particularly high risk of severe malarial anemia (e.g. blood group A: case-control OR 1.54, CI 1.22 1.96, P = 0.00039; family OR 1.51, CI 1.09 2.09, P = 0.014). The higher

risk of SA experienced by individuals with non-O blood groups may reflect a pathophysiological effect, for example accelerated clearance of erythrocytes bound to iRBC. 9 The analysis strongly supported the hypothesis that blood group O individuals are relatively protected from severe malaria in comparison to other blood groups, particularly blood group A and AB. 9

A study was carried out to show Heretability of diabetes mellitus in Ethiopian diabetics in prospective case control study of 859 diabetic probands and 1059 non-diabetics controls. There were 445 non-insulin dependent diabetic The study indicated that, mellitus ( NIDDM ) and 414 insulin dependent diabetes mellitus ( IDDM), in the diabetic probands. mellitus.11 From the above observations it appears that there is variation in difference in the relationship between blood groups, secretor status and their susceptibility to diseases . Lokking at the heterogenecity of the results, it is exceedingly difficult to arrive at the cause effect relationship of blood groups and diabetes mellitus . It is also extremely difficult to explain in what way, the ABO antigens offer protection or make persons more susceptible to disease. What is certain from the family and blood group studies is that heredity plays an important role in aetiology of diabetes mellitus. heredity plays an important role in genesis of diabetes

Thus as mentioned previously, in the aetiology that genetic inheritance of diabetes is accepted most widely, it then appears that , the genes for ABO blood groups and secretor

Se

genes along with the other genetic and environmental

factor might influence the degree of penetrance of a gene or genes responsible for diabetes mellitus.

The above reviews reveal that , there is a sizeable proportion of evidence for association between blood group antigens, secretor status and diabetes mellitus, from various parts of the world. However , there are very few reports involving subjects of Indian origin in this field. This warrants a study to be conducted to know the association between blood group antigens, secretor status and diabetes mellitus involving subjects of Indian origin.

ANNEXURE I

6.3 Objectives Of the study

To study distribution of blood groups among patients with

diabetes mellitus & secretor status compared to healthy individuals of both sexes of BLDES SHRI B.M.PATIL MEDICAL COLLEGE AND HOSPITAL in Bijapur.

ANNEXURE-II

METHODOLOGY

7.2 Method of collection of Data

Study group: This group will consist of specific group of

patients suffering with either Type I or Type II Diabetes Mellitus and attending Medical OPD and admitted patients in medical wards in BLDEUs SHRI B. M. Patil Medical College and Hospital in Bijapur. The patients are in age group of 17-65 yrs with confirmed Diabetes Mellitus. Study group includes both male and females subjects.

Control group: Normal healthy subjects attending Diabetic

clinic in the BLDEUs SHRI B. M. Patil Medical College and Hospital in Bijapur, will be selected for the control group.

Duration of study: From Feb 2013 to Jan 2014. Age of the subjects: In both the groups, subjects are in the
age group of 17-65 years will be included.

Size of sample: Both the control and study groups consisted

of 110 subjects (55 subjects each)

Sample size is calculated by assuming the error +2.53, by using the formula

n={ z /2 }2 E
Where z/2 = Value of Z at /2 % level of significance = Standard Deviation E = Permissible error

1)Determination of Diabetic status: The diabetic status

of each patient will be determined by using the criteria of National Diabetes Data Group of National Institute of Health. The criteria is as follows. Symptoms of diabetes plus random blood glucose conc. > 11.1 mmol/L (200mg/dl) OR Fasting plasma glucose > 7.0 mmol/L (126mg/dl) OR Two-hour plasma glucose > 11.1 mmol/L (200mg/dl) during an glucose tolerance test.

2) Determination of ABO and Rh blood group 3) Determination of Secretor and Non-secretor status

Inclusion criteria:
1. Only healthy subjects without any family history of diabetes mellitus and known chronic disease included in the study as control group. 2. Established diabetic patients of both type I and type II will be included in study group. 3. Confirmed diabetic patients whose blood sugar level will be controlled on taking oral hypoglycaemic drugs or insulin will be included in the study group. will

Exclusion criteria:
excluded from the study:

The following subjects will be

1. Subjects with malignancies like leukemia which leads to weakning or loss of blood group antigens on cell. 2. Subjects associated with gram negative septicemia, intestinal obstruction and carcinoma of colon or rectum which leads to acquired B antigen like activity. 3. Subjects with history of recently transfused nonspecific group blood and bone marrow

transplantation leading to presence of 2 separate cell population.

The following parameters will be recorded in the subjects:

I.Record of Physical Anthropometry of subjects. 1. Height (in centimetres): This will be measured with subject standing without their footwears nearest to 0.1 centimetres. 2. Weight (in kilograms): The subjects will be weighed in standardized machine with minimum clothing nearest to 0.1 kilogram. 3. Chest circumference: It will be measured at deep inspiration position at the level of the nipple with

minimum clothing with the help of standard tailor tape nearest to 0.1centimetre. 4. Body Mass Index (kilogram/meter2): This is calculated for each subject from weight in kgs and height in meters by using Quetlet index. II. Record of physiological parameters. 1. Pulse rate: It will be expressed as beats per minute by palpating right radial artery. 2. Blood pressure (SBP and DBP): It will be measured by mercury sphygmomanometer in mm of Hg. 3. Respiratory rate: It will be expressed as cycles per minute by manual method.

4.

Mean arterial pressure (MAP): It will be measured in mm

of Hg by using the following formula = DBP+1/3 pulse pressure (PP). III. Method of Assesing secretory status The presence of blood group antigens in the saliva of the subjects of both groups will be tested by using

Haemagglutination Inhibition Technique.

Statistical Analysis: Statistical analysis is done using Chi Square test for finding the presence of an association between attributes like blood groups, secretor status, sex etc.. The results are presented using bar diagrams.
a. Diagrammatic representation. b. Mean +/- Standard Deviation c. Chi square test. d. Correlation and Regression analysis.

7.3. Does the study require any investigation or intervention to be conducted on workers or other human or animals? Yes. The study requires recording of various physical and physiological parameters, as well as determination of ABO, Rh blood group & Secretor status. However, none of these are invasive and none will interfere with the normal physiology of the subjects. For this, an informed consent will be obtained from each subject (Format enclosed in Annexure IV).

7.4

Has

ethical

clearance

been

obtained

from

your

institution in case of 7.3? To be taken.

ANNEXURE-IV

B. L. D. E. U SHRI B.M. PATIL MEDICAL COLLEGE, HOSPITAL AND RESEARCH CENTRE, BIJAPUR

RESEARCH INFORMED CONSENT FORM

Title of the project:

A STUDY IF DISTRIBUTION

OF ABO BLOOD GROUPS AMONG PATIENTS WITH DIABETES MELLITUS AND THEIR SECRETOR STATUS

Principal investigator/ P.G.Guides name: DR.MANJUNATHAAITHALA MD PROF AND HEAD DEPARTMENT OF PHYSIOLOGY

1: PURPOSE OF RESEARCH:

I have been informed that this study will test relationship between Blood group, secretory status of the subject to his/her Diabetes mellitus. This study will be useful

academically as well as to find out association between Blood group, secretory status and Diabetes mellitus in patients and normal subjects of both sexes. 2: PROCEDURE: I understand that, the procedure of the study will involve determination of my blood groups, secretor status and diabetic status. Procedure is diagnostically invasive in nature.

(Collection of blood sample ) The procedure will not interfere with any of my physiological parameters and they are non invasive. 3: RISK AND DISCOMFORTS: I understand that, determination of my blood groups, secretor status and diabetic status will not cause any

discomfort to me and do not involve any risk to my health. 4: BENEFITS: I understand that my participation in the study may not have a direct benefit to me but this may have a potential beneficial effect in the field of Diabetes mellitus in future.

5: CONFIDENTIALITY:

understand

that

medical

information produced by this study will become part of institutional records and will be subject to the confidentiality and privacy regulation of the said institute. Information of a sensitive personal nature will not be a part of medical record, but will be stored in investigators research file and identified only by a code number. The code key connecting name two numbers will be kept in a separate secured location. If the data to be used for publication in the medical literature and for teaching purpose no names will be used and other identities such as photographs, audio and video tapes will be used only with my special written permission. I understand I may see the photographs and the video tapes and have the audio tapes before giving this permission. 6: REQUEST FOR MORE INFORMATION: I understand that I may ask more questions about the study at any time. Concerned researcher is available to answer my questions or concerns. I understand that I will be informed of any significant new findings discovered during the course of this study which might influence my continued participation. If during the study or later, I wish to discuss my participation in all concerns regarding this study with a person not directly involved, I am aware that the social worker of the hospital is available to talk with me. A copy of this consent form will be given to me to keep for careful re-reading.

7: REFUSAL OR WITHDRAWAL OF PARTICIPATION: I understand that my participation is voluntary and may refuse to participate or may withdraw my consent and discontinue participation in the study at any time without prejudice to my present or future care at this hospital. I also understand that researcher may terminate my participation in this study at any time after she/he has explained the reasons for doing so and had helped arrange for my continued care by my physician or physical therapist if this is appropriate 8: INJURY STATEMENT I understand that in unlikely event of injury to me resulting directly from my participation in this study, if such injury were reported promptly, then medical treatment will be available to me, but no further compensation would be provided. I

understand that by my agreement to participate in this study I am not waiving any of my legal rights. I have explained to ___________________________(Name of subject) the purpose of the research, the procedure required and the possible risk and benefits to the best of my ability.

ANNEXURE-II
CONSENT FORM
I confirm that Dr.Muddaser Mujawar_____________ has

explained to me the purpose of research, the study procedure that I will undergo, and the possible risk and discomforts as well as benefits that I may experience. Alternative to my participation in the study, I have also been to give my consent form. Therefore, I agree to give consent to participate as a subject and this research project.

Participant

Date:

Signature of witness

Date:

Modified from Portney L.G. Watkins M.P., in Foundation of Clinical Research, Second Edition, New Jersey, Prentice Hall Health 2000. (A

CLINICAL PROFORMA

Title : A STUDY OF DISTRIBUTION OF ABO BLOOD GROUPS AMONG PATIENTS WITH DIABETES

MELLITUS AND THEIR SECRETOR STATUS

Name:
Sex:

Age:

Address & phone no:

General physical examination

PR:

BP:

Wt:

Ht:

Temperature:

RR:

Systemic Examination:
Cardiovascular system:

Respiratory system:

Central nervous system:

Per abdomen:

PARAMETERS FOR STUDY:

1. Blood Sugar Level 2. Fasting 3. Post-Prandial 4. Random 5. Blood Group(ABO & Rh) 6. Secretor status

Signature of PG student

Signature of Guide & HOD

BIODATA OF GUIDE:

1. Name 2. Designation Physiology. 3. Date of Birth 4. Qualification :

: :

Dr. Manjunatha Aithala. Professor and Head Dept of

: 26/06/1964. M.B.B.S [Jan1993, Mahadevappa

Rampure Medical College, Gulbarga. M.D [SEP 2001, B.L.D.E.US Shri B.M.Patil Medical

college Bijapur] 5. KMC Registration no 6. College address : 38820 : Department of Physiology B.L.D.E.US Shri B.M.Patil Medical

College, Bijapur - 586103 7. Teaching Experience : UG Teaching since 1994. : PG Teaching since 2007. 8. Contact no : 9902103620.

INVESTIGATORS BIO-DATA

1.

Name

Dr. Muddaser Mujawar

2.

Qualification

B.H.M.S

[2010,

A.M.SHAIKH

HOMOEOPATHIC MEDICAL COLLEGE, BELGAUM ]

3. Registration No

: A. 10850

4. Address for Correspondence : Department of Physiology B.L.D.E.U Shri .B.M.Patil Medical college Bijapur. 586103

5. Mobile no.

: 9886003203

LIST OF REFERENCES

1. L. Qi, M. C. Cornelis, P. Kraft et al., Genetic variants in ABO blood group region, plasma soluble E-selectin levels and risk of type 2 diabetes, Human Molecular Genetics, vol. 19, no. 9, Article ID ddq057, pp. 18561862, 2010.
2. El Hajj, J. G. Hashash, E. M. K. Baz, H. Abdul-Baki, and A. I. Sharara, ABO blood group and gastric cancer Southern Medical Journal, vol. 100, no. 7, pp. 726727, 2007.

3. The relationship between blood groups and disease( David. J. Anstee.) 4. Variant ABO Blood Group Alleles, Secretor Status and Risk of Pancreatic Cancer: Results from the Pancreatic Cancer Cohort Consortium(Brian M. Wolpin, Peter Kraft, Mousheng Xu, Emily Steplowski.) 5. Biological and clinical aspects of ABO blood group system. J. Med. Invest. 2008;55:174- 182. Hosoi E.
6. Advanced Topics in Blood Type Diet. Secretors and Non-secretors.( Dr. D'Adamo )

7.Association of ABO blood groups with diabetes mellitus Muhammad Kamil*, Hamid Ali Nagi Al-Jamal and Narazah Mohd Yusoff, Citation: Libyan J Med 2010, 5: 4847 - DOI: 10.3402/ljm.v5i0.4847 Libyan J Med 2010. 2010 Muhammad Kamil et al. 8. Ayub Med Coll Abbottabad. Frequency of ABO and Rhesus blood groups in District Swat, Pakistan \ Khattak ID, Khan TM, Khan P, Shah SM, Khattak ST, Ali A. 2008 Oct-Dec;20(4):127-9. 9.The ABO blood group system and Plasmodium falciparum malaria. bloodjournal.hematologylibrary.org/content/110/7/2250.f... Christine M. Cserti1 and Walter H. Dzik2.

10.Common variation in the ABO glycosyltransferase is associated

with susceptibility to severe Plasmodium falciparum malaria Hum Mol Genet. 2008 February 15. Andrew E. Fry,,Michael J. Griffiths.

11. Diagnosis and Classification of Diabetes Mellitus American Diabetes Association

12. J. R. Storry and M. L. Olsson, The ABO blood group system revisited: a review and update,Immunohematology, vol. 25, no. 2, pp. 4859, 2009. 13. Qureshi M, Bhatti R. Frequency of ABO blood groups among the diabetes mellitus type 2 patients. J Coll Physician Surg Pak. 2003; 8: 4535. 15. O. Wu, N. Bayoumi, M. A. Vickers, and P. Clark, ABO(H) blood groups and vascular disease: a systematic review and metaanalysis, Journal of Thrombosis and Haemostasis, vol. 6, no. 1, pp. 6269, 2008. 16. P. V. Jenkins and J. S. O'Donnell, ABO blood group determines plasma von Willebrand factor levels: a biologic function after all? Transfusion, vol. 46, no. 10, pp. 18361844, 2006. 17. M. Campos, W. Sun, F. Yu et al., Genetic determinants of plasma von Willebrand factor antigen levels: a target gene SNP and haplotype analysis of ARIC cohort, Blood, vol. 117, no. 19, pp. 52245230, 2011. 18.Wolpin BM, Chan AT, Hartge P, et al. ABO blood group and the risk of pancreatic cancer. J Natl Cancer Inst. 2009;101:42431.

19. Risch HA, Yu H, Lu L, Kidd MS. ABO blood group, Helicobacter pylori seropositivity, and risk of pancreatic cancer: a case-control study. J Natl Cancer Inst. 2010;102:5025.