ETHICS IN

MEDICAL
RESEARCH
Principles of essentiality

– Refers to whether the research is considered to be absolutely

essential after a due consideration of the existing scientific
knowledge in the proposed area of research. This should be
scrutinized by an independent and responsible body of persons
who, after careful consideration, come to the conclusion that the
research is likely to benefit the humanity or environment
Principles of voluntariness, informed
consent, and community agreement

– Research participants should be fully apprised of the research and

the associated risks and benefits. The participants should be
informed of the right to abstain from the research or withdraw
consent at any time.
– Where research entails treating any community, the principles of
voluntariness and informed consent apply to the community as a
whole and to each individual member. In case a person is
incapable of giving consent, a legally acceptable guardian should
give the informed consent.
Principles of non-exploitation

– The participants should be fully apprised of all the possible dangers

that may arise during the research so that they can appreciate all
the physical and psychological risks. Each research should include
an in-built mechanism for compensation for the human
participants either through insurance cover or by any other
appropriate means to cover foreseeable and unforeseeable risks,
and provide remedial action and comprehensive aftercare.
Principles of privacy and
confidentiality

– The identity and records of the participants are as far as possible

kept confidential (except when required for legal reasons). This is
to avoid any form of hardship, discrimination or stigmatization as a
consequence of having participated in the research.
Principles of precaution and risk
minimization

– Due care and caution should be taken at all stages of the research
and experiment to ensure that the research participant and those
affected by it including the community are put to the minimum
risk, suffer from no known irreversible adverse effects, and
generally, benefit from the research or experiment. There should
be a plan for interim reviews to detect whether any intervention
arm (active or control) is associated with increased risks, so that
undue harms are avoided by stopping the research.
Principles of professional competence

– Research should be conducted by competent and qualified persons

who act with total integrity and impartiality and who have been
made aware of the ethical considerations to be borne in mind in
respect of such research or experiment.
Principles of accountability and transparency

– The research or experiment should be conducted in a fair, honest,

impartial, and transparent manner after full disclosure is made by
those associated with the research or experiment of each aspect of
their interest in the research, and any conflict of interest that may
exist. Full and complete records of the research should be retained
for such reasonable period as may be prescribed or considered
necessary for the purposes of post-research monitoring, evaluation
of the research, conducting further research, and scrutiny by the
appropriate legal and administrative authority, if necessary.
 Principles of the maximization of the public
interest and distributive justice
– The research or experiment and its subsequent application should be conducted
and used to benefit all human kind (and not just those who are socially better off),
in particular, the research participants themselves and or the community from
which they are drawn.
Principles of public domain

– The research findings should be brought into the public domain so

that its results are generally made known through scientific and
other publications. This would help in consolidating the scientific
knowledge base of the field being studied and would prevent the
undue replication of studies which pose risks to some subjects.
Principles of totality of responsibility

– Professional and moral responsibility should be

observed, for the due observance of all the principles,
guidelines, or prescriptions of those directly or
indirectly connected with the medical research. This
extends to the institutes where this research is carried
out, as well as the sponsors of the research. The
research should be duly monitored and constantly
subject to review and remedial action at all stages
 The ten points of the Nuremberg Code
1. The voluntary consent of the human subject is absolutely essential.

2. The experiment should be such as to yield fruitful results for the good of
society, unprocurable by other methods or means of study, and not random
and unnecessary in nature.

3. The experiment should be so designed and based on the results of animal

experimentation and a knowledge of the natural history of the disease or other
problem under study that the anticipated results will justify the performance of
the experiment.

4. The experiment should be so conducted as to avoid all unnecessary physical

and mental suffering and injury.
 Nuremberg Code

5.No experiment should be conducted where there is an a

priori reason to believe that death or disabling injury will occur;
except, perhaps, in those experiments where the experimental
physicians also serve as subjects.

6. The degree of risk to be taken should never exceed that determined

by the humanitarian importance of the problem to be solved by the
experiment.

7. Proper preparations should be made and adequate facilities

provided to protect the experimental subject against even remote
 Nuremberg Code
8. The experiment should be conducted only by scientifically qualified
persons. The highest degree of skill and care should be required
through all stages of the experiment of those who conduct or engage
in the experiment.

9. During the course of the experiment the human subject should be

at liberty to bring the experiment to an end if he has reached the
physical or mental state where continuation of the experiment seems
to him to be impossible.

10. During the course of the experiment the scientist in charge must
be prepared to terminate the experiment at any stage, if he has
probable cause to believe, in the exercise of the good faith, superior
skill and careful judgment required of him that a continuation of the
 WMA DECLARATION OF HELSINKI

Ethical principles for medical research involving human subjects

(Attached as separate file)
WMA DECLARATION OF HELSINKI

❖ The Declaration of Geneva of the WMA binds the physician with the words, “The
health of my patient will be my first consideration,” and the International Code of
Medical Ethics declares that, “A physician shall act in the patient’s best interest
when providing medical care.”

❖ It is the duty of the physician to promote and safeguard the health, well-being
and rights of patients, including those who are involved in medical research. The
physician’s knowledge and conscience are dedicated to the fulfilment of this duty.

❖ Medical progress is based on research that ultimately must include studies

involving human subjects.

❖ The primary purpose of medical research involving human subjects is to understand

the causes, development and effects of diseases and improve preventive, diagnostic
and therapeutic interventions (methods, procedures and treatments). Even the best
proven interventions must be evaluated continually through research for their safety,
effectiveness, efficiency, accessibility and quality.
WMA DECLARATION OF HELSINKI

❖ Medical research is subject to ethical standards that promote and

ensure respect for all human subjects and protect their health and rights.
❖ While the primary purpose of medical research is to generate new
knowledge, this goal can never take precedence over the rights and
interests of individual research subjects.
❖ It is the duty of physicians who are involved in medical research to
protect the life, health, dignity, integrity, right to self-determination,
privacy, and confidentiality of personal information of research subjects.
The responsibility for the protection of research subjects must always
rest with the physician or other health care professionals and never with
the research subjects, even though they have given consent.
 WMA DECLARATION OF HELSINKI

❖ Physicians must consider the ethical, legal and regulatory norms and standards
for research involving human subjects in their own countries as well as
applicable international norms and standards. No national or international
ethical, legal or regulatory requirement should reduce or eliminate any of the
protections for research subjects set forth in this Declaration.

❖ Medical research should be conducted in a manner that minimizes possible harm

to the environment.

❖ Medical research involving human subjects must be conducted only by

individuals with the appropriate ethics and scientific education, training and
qualifications. Research on patients or healthy volunteers requires the
supervision of a competent and appropriately qualified physician or other health
care professional.
 WMA DECLARATION OF HELSINKI

❖ Physicians who combine medical research with medical care

should involve their patients in research only to the extent that this
is justified by its potential preventive, diagnostic or therapeutic
value and if the physician has good reason to believe that
participation in the research study will not adversely affect the
health of the patients who serve as research subjects.
❖ Appropriate compensation and treatment for subjects who are
harmed as a result of participating in research must be ensured.
– Vulnerable Groups and Individuals
– Scientific Requirements and Research Protocols
– Privacy and Confidentiality
– Use of Placebo
– Post-Trial Provisions
– Research Registration and Publication and Dissemination of Results
– Research Ethics Committees
– Informed Consent
Unethical research background

The Nuremberg Medical Trial of 1946–47 and

the ensuing Nuremberg Code addressed in
particular the absence of consent of those
involved in research in Nazi experiments, and
as a consequence formulated the principle of
informed consent for the first time on an
international level
Unethical human experimentation
history
– There were controversies over whether adding antibiotics or
homoeopathic drugs to traditional surgery would improve
wounded soldiers’ chances of survival.
Unethical human experimentation
history
Healthy prisoners were given injections from the
festering tissues of other inmates who had wound
infections. In some people, small pieces of wood and
glass were placed in open wounds, in order to mimic
war injuries more realistically.
Unethical human experimentation
history
The victims were then treated with homoeopathic
preparations or various applications of
sulfonamides; some received no therapy at all.
About a third of the victims died. All these
experiments followed a scientific logic that was
outdated at the time, and which took no account
whatever of the wellbeing of those involved in
research. The surviving victims had irreversible
physical damage and severe psychological trauma.
Unethical human experimentation
history
Experiments in the context of aviation
medicine were aimed at finding methods to
help pilots survive after their planes had
been hit at very high altitudes, or after an
emergency landing at sea. The experiments,
carried out in the Dachau concentration
camp, focused on physiological questions,
such as the effects on the human body of low
pressure at high altitude, or of drinking salt
water
Unethical human
experimentation history
The researchers responsible, such as Siegfried Ruff,
Sigmund Rascher, and Georg Weltz, were all associated
with university institutes or the German Air Force. For the
high-altitude experiments, about 200 people were chosen
from the camp prisoners, at least 70 of whom died during
the experiments in a specially designed low-pressure
cabin, or were killed afterwards to study the pathological
changes in their brains.
Unethical human experimentation
history

Tuskegee Syphilis Study

The study took place in Macon County,
Alabama, the county seat of Tuskegee
referred to as the "Black Belt" because of its
rich soil and vast number of black
sharecroppers who were the economic
backbone of the region. The research itself
took place on the campus of Tuskegee
Institute.
Unethical human experimentation
history
The goal was to “observe the natural history
of untreated syphilis” in black populations.
But the subjects were unaware of this and
were simply told they were receiving
treatment for bad blood. Actually, they
received no treatment at all. Even after
penicillin was discovered as a safe and
reliable cure for syphilis, the majority of men
did not receive it.
Unethical human experimentation
history

▪ A total of 600 men were enrolled in the study. Of this group 399, who had
syphilis were a part of the experimental group and 201 were control subjects.
Most of the men were poor and illiterate sharecroppers from the county.
▪ There were no proven treatments for syphilis when the study began. When
penicillin became the standard treatment for the disease in 1947 the medicine
was withheld as a part of the treatment for both the experimental group and
control group.
 Unethical human
experimentation history
While the panel concluded that the men participated in the study
freely, agreeing to the examinations and treatments, there was
evidence that scientific research protocol routinely applied to human
subjects was either ignored or deeply flawed to ensure the safety and
well-being of the men involved. Specifically, the men were never told
about or offered the research procedure called informed consent.
Researchers had not informed the men of the actual name of the study,
i.e. "Tuskegee Study of Untreated Syphilis in the Negro Male," its
purpose, and potential consequences of the treatment or non-
treatment that they would receive during the study.
Unethical human experimentation
history

The men never knew of the debilitating and life

threatening consequences of the treatments they
were to receive, the impact on their wives,
girlfriends, and children they may have conceived
once involved in the research. The panel also
concluded that there were no choices given to the
participants to quit the study when penicillin
became available as a treatment and cure for
syphilis
Reference

– Avasthi A, Ghosh A, Sarkar S, Grover S. Ethics in medical research:

General principles with special reference to psychiatry research.
Indian J Psychiatry. 2013 Jan;55(1):86-91. doi:
10.4103/0019-5545.105525. PMID: 23440168; PMCID: PMC3574464.

– Roelcke V. Nazi medicine and research on human beings. The

Lancet. 2004 Dec 1;364:6-7.
– about the USPHS syphilis study | Tuskegee University [Internet].
Tuskegee.edu. 2021 [cited 27 February 2021]. Available from: https://
www.tuskegee.edu/about-us/centers-of-excellence/bioethics-center/
about-the-usphs-syphilis-study
 Stress Management

Prof Asad Tamizuddin Nizami

MBBS MCPS (Medical Education) FCPS (Psychiatry)
Fellowship in Health Systems Research (UK)
Fellowship in Old Age Psychiatry (UK)

Professor of Psychiatry
Rawalpindi Medical University

Chairman Institute of Psychiatry

Benazir Bhutto Hospital Rawalpindi

Member Federal Mental Health Authority Islamabad

Member Faculty of Psychiatry College of Physicians & Surgeons Pakistan
Vice President Pakistan Psychiatric Society
What are the Qualities of a Good Doctor?

 Presence of medical knowledge and skill

 Precision in diagnosis and management of illnesses

 Dedication, Empathy, Competence and Compassion

 Appearance of a doctor should be friendly,

gracious, courteous, tolerant and humble
What are the Qualities of a Good Doctor?

• Should take time out to offer the patient explanation

about both the illness and the treatment prescribed

• Keep the patient’s interest in mind, and prescribes

while keeping in view the patient’s economic status

• Sincerity of the doctor both towards the patients

and the profession
How to do it ?
 Throughout her teens and early 20s, Angie
admitted that she suffered bouts of
depression after her mother death

“I was unwell with depression,

which no one ever discussed” Confessed about her
depression on TV. She tells
the world how she struggled
with anxiety and depression
What is Stress?
 A perceptual phenomenon arising from comparison
between the demands on the person and his ability to
cope

IMBALANCE

Great Individual variations

Stages of Stress
How Stress presents - Psychologically
How Stress presents - Socially
Health Effects
Individual differences in response to stress

Personality

&

Intelligence



Management Strategies
• Managing Emotions

• Behavioral Techniques
• Talk it out
• Anger management

• Cognitive Techniques
• Positive thinking
• Stress Diary

• Others
• Relaxation techniques
• Avoid Burnout
Talk it out !!!
Managing Anger
Positive Thinking
Avoiding Burn Out
Relaxation Techniques
 Summary
• Make sure that enough sleep is taken
• Exercise
• Relaxation techniques
• Proper diet
• Breathing techniques (proper breathing)
• Engage in positive self talk
• Involvement in pleasurable activities
• Anxiety diary
• Consulting a mental health professional in case of
increase in stress despite all measures
PERCEIVED STRESS AMONG STUDENTS
In Medical/Dental & Allied Health Universities
In Pakistan Due to COVID 19 Pandemic
Why students ??

The COVID Pandemic had become synonymous not only with wide spread
physical morbidity and mortality but also with horrendous Mental Health
and Psycho Social Suffering.

Since level of Stress and Anxiety was found to be high in Healthcare

Professionals during Covid-19, it was pertinent that it might render
Medical and Allied Specialties Students also more vulnerable to stress
in this challenging time.
Methodology

A survey link using

The study took place at the A webinar on Mental Health “Perceived Stress Scale” was
Data was analyzed using
Institute of Psychiatry and Psychosocial Support shared and the participants
SPSS 22.0. A p value <0.05
(IOP) Rawalpindi Medical was organized in April 2020 and were invited to
was considered significant.
University (RMU) in collaboration with SYNCH participate after a formal
consent.
 PERCEIVED STRESS SCALE
IN THE LAST MONTH 0=NEVER 1=ALMOST NEVER 2=SOMETIMES 3=FAIRLY OFTEN 4=VERY OFTEN
HOW OFTEN HAVE YOU

1. been upset because of something that happened unexpectedly? 0 1 2 3 4

2. felt that you were unable to control the important things in your life? 0 1 2 3 4

3. felt nervous and “stressed”? 0 1 2 3 4

4. felt confident about your ability to handle your personal problems? 0 1 2 3 4

5. felt that things were going your way? 0 1 2 3 4

6. found that you could not cope with all the things that you had to do? 0 1 2 3 4

7. been able to control irritations in your life? 0 1 2 3 4

8. felt that you were on top of things? 0 1 2 3 4

9. been angered because of things that were outside of your control? 0 1 2 3 4

10. felt difficulties were piling up so high that you could not overcome them? 0 1 2 3 4
 Field of study %
MBBS 78.4
BDS 3
RESULTS AHS
Clinical Psych
12.9
3.6
Pharm D 2.1
Year of study 1st year 24.3
2nd year 21.3
3rd year 22.5
4th year 14.1
Final year 17.1
Graduated 0.6
RESULTS

• Percentages of Perceived Stress among study sample (N=333)

 GENDER DIFFERENCES
Males Females 95% CI

n= 103 n= 230

Scales M SD M SD LL UL Cohen’s d

Perceived 19.99 5.91 21.95 4.26 -3.0 -.83 0.38

Stress
 was
alarmingly high
urgent intervention by the
Medical and Dental
Universities
 Thank you

ioprmu@gmail.com
Behavioural Sciences ?

HUMAN BEHAVIOUR
 Behaviour Sciences

Psychiatry

Mental Health
Psychology
Sociology
Anthropology
Islamabad …… July 2019
Almost half of the world's population live in a country
where, on an average, there is one psychiatrist or
less to serve 200,000 people or more.
Institute of
Psychiatry
 Integrated “Undergraduate
Research Curriculum” (IUGRC)
Rawalpindi Medical University
Rawalpindi

D R KHAU LA NOREEN
AS S IS TAN T PROFES S OR
COM M U NIT Y M ED ICIN E
RAW ALPIND I M ED ICAL U NIVERSI T Y
RAW ALPIND I
RESEARCH IS CENTRAL TO MOTTO OF THE
UNIVERSITY
Rod of Asclepius. Caduceus
BACKGROUND

Medical Undergraduate Research is highly

demanded;
 7 star doctor PMDC

 GMC UK:
“tomorrow must be equipped with
research skills”.
 Part of MBBS Curriculum (PMDC)
IUGRC

IUGRC
40 pages Doc
 Vision of IUGRC

To create culture of excellence for future seven star

doctors by teaching highest standard of research
and medical education, striving for implementation
of innovative way having strong impact on clinical
outcomes, population health and health care
services delivery across the nation
Mission & Motto of the
RAWALPINDI MEDICAL
UNIVERSITY
WHAT IS RESEARCH !

What is Research
 3/1/2021

RESEARCH
 It is the path directed by;
“ Almighty Allah-Tallah”
 what, why & how {are basic trigger of research}
(Al-Quran)
 Research is global unifying force .

 Research is a common Human Heritage.

11
RESEARCH THINKING
 Links behind happenings
COVID-19
 Research demands Curious and Suspicious
minds
(Alexander Fleming – Penicillin )
 From crude to precise /refine
apparent phenomenon-----matter to atom
(deductive reasoning)
 Explanation of happenings---/ sub-
processes
(smoking & short life expectancy)
More links leads to more options to control health
problems
 3/1/2021

WHAT IS RESEARCH
▪ Re- is a systematic quest for new
knowledge.
▪ It is visiting, visiting and re-visiting upon
some query (doubt).
▪ Research is way of thinking & examining
critically things/phenomenon around in
professional context (COVID-19 pandemic)
(Discovery of AIDS )
▪ Research inform Policy and Decision
making.
▪ Re- thinking start from common sense but
it is a high IQ supreme human activity.
13
 3/1/2021

RESEARCH IN YOUR IMMEDIATE RELEVANCE

Health Research may be defined as

“ a systematic process of collection,
Summarization, analysis, interpretation of
data, and making inference to answer the
question imposed.

15
 3/1/2021

RESEARCH
I. Research generates knowledge and knowledge is power
for development
II. Research informs attitudes with which people think
about themselves and their world. It is under standing of
research in people and capacity to conduct research that
leads to development of a nation.
III. “Because we are poor nation, we cannot afford not to
do research” (Nehru India )
IV. Our population, issues, our resource & challenges;
 Gaps in health status / health indicators indicate area of need
 Attitudes & behavior in matter of health & disease.
 Health system
 Be focused; think within specialty or professional boundaries
 Infectious diseases, NCDs, Social & behavioral disorders

16
RESEARCH THINKING
 Thinking micro details-Hazrat Ali (KAW)
“ wise man is not who knows big things but the person who
knows small things”. Research is study of ultimate facts
 Research is an approach to satisfy human
curiosity/ or test ideas / assumptions
(conceptual framework of research to practical framework of
research)
 Research is a way to find solutions of the
problems
 Research is a way to relieve apprehensions or
to reduce uncertainties
 MOTIVATION IN RESEARCH

 Why its important to carry out research at undergraduate level?

This is a question of fundamental importance. The possible motives
for doing research may be either one or more of the following:
 Desire to get a research orientation at undergraduate level along with
its consequential benefits
 This attribute encompasses a range of aptitudes linked to the
research process, evidence-based practice
 You prove your worth as a researcher
 Academia runs on Publish-or-perish
 Problem solving current pandemic , Poverty, hunger, social and racial
tension, natural disasters, health related issues, outbreaks
EVIDENCE BASED PRACTICES
RESEARCH !!!
Health promotion, educating patients and communities and the
development of reflective learning
 Desire to get intellectual joy of doing some creative work
 Desire to be of service to society
 Desire to get respectability
 Different communities may have unique problems
 Looking for fresh solutions
 An opportunity to connect with other intellectuals

“To direct their education, research and service activities towards

addressing the priority health concerns of the community, region and/or
nation they
have the mandate to serve.”
IUGRC

…
IUGRC
40 pages Doc
 UGME CURRICULUM RENEWAL MAP 2019

OUTCOME
New IUGRC Curriculum
SEVEN STAR DOCTORS & International Standards

Task Internal Stakeholders External

Force process Modular Consultation
Formation of curriculum Educational
Need assessment
Process IUGRC Team Extensive mapping team, Faculty Experts
Curricular review
of existing (Basic&Clini
of different
curriculum cal sciences) medical college

Community service Health Equity Advocacy

Principles

Research Multi Disciplinary Approach Scholar ship

Curriculum Integration Continuous Quality Improvement Critical thinking
Renewal
Goal Professionalism longitudinal theme self directed learning

Mission Service Truth Wisdom

Principle: “Fully integrated scaffold research curriculum through 5
years”

5 Advance health
research module
Experiential •Systematic Review
4. Research
•Qualitative research
•Grant writing projec
Module
Basic health research
• Epidemiology &
Biostatistics
3.module II • (IUGRC-IV)
• Inferential Statistics
(IUGRC-IIl)
• Group research
project(SRC-IV)
•Pilot project(Household
survey) (SRC-III)

2. Basic health research module I

• Descriptive Statistics (IUGRC-II)
• Sampling techniques
•Clinical survey project using
secondary data (SRC-II) ❖ Theoretical component
❖ (IUGRC 1-V)
1.Foundation module ❖ Practical Research Component
• Introduction to Health Research (IUGRC-I)
• Research Ethics ❖ (Student Research component
• Role plays (SRC-I) SRC 1-V) 24
• Journal club
 Research Teachings of
1st year –Final year MBBS

25
Principle: “Fully integrated scaffold research curriculum through 5
years”

5 Advance health
research module
Experiential •Systematic Review
4. Research
•Qualitative research
•Grant writing projec
Module
Basic health research
• Epidemiology &
Biostatistics
3.module II • (IUGRC-IV)
• Inferential Statistics
(IUGRC-IIl)
• Group research
project(SRC-IV)
•Pilot project(Household
survey) (SRC-III)

2. Basic health research module I

• Descriptive Statistics (IUGRC-II)
• Sampling techniques
•Clinical survey project using
secondary data (SRC-II) ❖ Theoretical component
❖ (IUGRC 1-V)
1.Foundation module ❖ Practical Research Component
• Introduction to Health Research (IUGRC-I)
• Research Ethics ❖ (Student Research component
• Role plays (SRC-I) SRC 1-V) 27
• Journal club
 First year MBBS
FOUNDATION MODULE
Research component Course content Teaching strategy
Theoretical •How to Read & Write Research Interactive lecture
IUGRC-1 Article
•General principles of Ethics in
Research
Practical critical review of scientific paper Journal Club
SRC-1 Group presentations
Role plays
Second year MBBS
BASIC RESEARCH MODULE - I

Research component Course content Teaching strategy

Theoretical •Descriptive Statistics Interactive lecture
IUGRC-II •Sampling & sample size
estimation

Practical •Hands on session: Using SPSS SPSS Workshop (descriptive

SRC-II Software(Descriptive data ) statistics)
•Small scale research projects Group presentations
/Clinical survey Poster/oral Presentation 28
 Third year MBBS
BASIC RESEARCH MODULE - II
Research component Course content Teaching strategy
Theoretical •Theoretical aspects of Inferential Interactive lecture
IUGRC-III Statistics and
Practical •Hands on session: Using SPSS SPSS Workshop
SRC-III Software Log book (daily entry )
•Execution of Pilot project Reflective writing
(Community based House hold survey) Portfolios
Seminar/symposia
Fourth year MBBS
EXPERIENTIAL RESEARCH MODULE
Research component Course content Teaching strategy
Theoretical •Theoretical aspects of Epidemiology, Interactive lecture
IUGRC-IV Biostatistics, Research Methodology
Practical •Hands on session: Using SPSS SPSS Workshop
SRC-IV Software Log book (daily entry )
•Execution of Group Research Project Poster/Oral presentation
execution (GRP) Research Seminar/Symposia
Final year MBBS
ADVANCE RESEARCH MODULE
Research component Course content Teaching strategy

Theoretical •Theoretical aspects of Advance Interactive lecture

IUGRC-V Research & Grant proposal writing
Practical •Grant proposal project presentation Group presentation 29
SRC-V
30
 SCHEDULE OUTLINES OF IUGRC
Total Hrs allocated to Hrs allocated to IUGRC a Actual Hrs invested in
Year of MBBS Com-Med by PMDC Visible IUGRC teachings Course title
course within overall MBBS &
timetable class Pattern

I 25 4hrs 4 x 4 = 16 hrs Introduction to Health research

(1/4th class, 4 Parallel LGIS) (annexure-I)

II 25 6hrs 6 x 4 = 24 hrs Basics of Health Research-I (Annexure-II)

(1/4th class,
24Parallel LGIS)

III 50 8hr 8 x 4 = 32hrs Basics of Health Research-II (Annexure-III)

(1/4th class,
4Parallel LGIS)

14 x 2 x 10 =
IV 150 20hrs 280hrs Experiential learning
Formal Year of 10 contact sessions c Each (Group based (Annexure-IV)
CM comprising 2hrs teachings)

V 4 4 hrs 4 x 4 = 16 hrs Advance Health Research

(added) (1/4th class, 4 Parallel (Annexure-V)
LGIS)

250hrs total 42hrs 368 hrs

(254) (15% of total hrs allocated to CM by visible time effort in addition to informal contact sessions
Theme:
First Session
Underlying idea is to introduce fresh medical students to health research in a soft way and to inculcate a pro research
attitude in students as a need of their profession. First year MBBS Students will be Introduced to meanings & concept of
Health Research & Health Research Methods, fundamental types & drivers of research and research need in professional
work.
Broa Major syllabus with sub- Learning objectives Teaching Assessment tools Suggested reading
d topics strategy and sources
topic
Discussion will cover; At the end of the LGIS 1 MCQs of level C1 - Text Book of
introduction to Health Research (HR) & Health Research

• Definitions of Health session students 1hr contact to C3 will cover this Public Health &
Research & Concept of should be able to; session in session teachings in Community
Health research methods - Describe 2-4 parallel relevant block Medicine by
. meanings of HR classes will be examination in pool Muhammad
• Background and value of & HRM conducted by of total 04 MCQs. Ilyas,
research in health & - Appreciate role Senior Faculty Result / marks Muhammad
human development of HR in (Assistant obtained will Irfanullah
• Fundamental types and healthcare professor or contribute towards Siddique
fields of health research practices and Subject Internal assessment - Short Book of
covering; human Specialist) (IA) under total 04 ‘Research
- Basic & Applied Research development marks in 1s t Prof. Methodology
- Quantitative & - Differentiate MBBS exam. and Biostatistics”
Qualitative Research among various by Prof.Sira Afzal
- Collaborative & types and fields - WHO : Eastern
Multidisciplinary of HR Mediterranean
research - Explain different Region. 32
- Health Research triangle drivers of HR
 Second Session
Theme: Students will introduced to basic characteristics of Research Process and attributes of the researcher to
understand scientific needs of research activity and the capacities required to undertake health research project
Broa Major syllabus with sub- Learning objectives Teaching Assessment tools Suggested reading
d topics strategy and sources
topic
Discussion will cover; At the end of the LGIS 1 MCQs of level C1 - Text Book of
basic Nine (09) session students 1hr contact to C3 will cover this Public Health &
characteristics of Research should be able to session in session teachings in Community
Characteristics of research process and researcher.

Process and attributes of the - Explain meanings 2-4 parallel relevant block Medicine by
researcher including; of various classes examination in pool Muhammad
Charac-Re-Process: characteristics of conducted by of total 04 MCQs. Ilyas,
Systematic, Rigorous, health research Senior faculty Result / marks Muhammad
Controlled, process so as to obtained will Irfanullah
valid, verifiable , differentiate contribute towards Siddique
reproducible, empirical, research activity Internal assessment - Short Book of
critical, logical reasoning and from non- (IA) under total 04 ‘Research
use of probability theory, research activity. marks in 1s t Prof. Methodology
Researcher attributes: - Elaborate MBBS exam. and Biostatistics”
Honesty, Positivity of ingredients of by Prof. Sira Afzal
purpose, Objectivity, researcher - WHO : Eastern
Taking advantage of above - Appreciate the Mediterranean
terms discussion will cover importance of Region. A
intro to basic capacities commands . Practical Guide
including medical statistics for Health R
33
 Third Session
Theme:
Students will be introduced towards general principles of ethics in research so they could perceive ethical needs of the
health research
Major syllabus with sub- arning objectives Teaching Assessment tools Suggested reading sources
topics strategy and
Discussion on Health At the end of the LGIS 1 MCQs of level C1 - Text Book of Public
Research ethics focusing; session students 1hr contact to C3 will cover this Health & Community
involving human should be able to; session in session teachings in Medicine by
subjects. - Appreciate value 2-4 parallel relevant block Muhammad Ilyas,
- Ethics in research of ethics in classes, examination in pool Muhammad Irfanullah
methods* conduct of Conducted by of total 04 MCQs. Siddique
- Responsibility for ethics Health Research. Senior faculty. Result / marks - Short Book of
in Background, - Explain basic obtained will ‘Research
Nuremburg code and ethical principles contribute towards Methodology and
importance of ethics in of health Internal assessment Biostatistics” by
current research trends. research. (IA) under total 04 Prof.Sira Afzal
- General ethical - Interpret the marks in 1s t Prof. - WHO : Eastern
principles including application of MBBS exam. Mediterranean Region.
explanation of 04 basic data collection A Practical Guide for
principles of ethics Health Researcher
Beneficence, non- - Explain ethics of Srviers-30.
maleficence, respect and research - USMLE- High Yield
justice. methods Biostatistics. 34
 Fourth Session
Theme:
Students will be introduced to basic elements of health research proposal writing so they would be able to conceive their
research ideas and perceive their learning requirements for undertaking a small research project in future years. Class
room teachings will be based on discussion on an “abstract or full text article of a public health article published in some
standard medical journal.
Bro Major syllabus with sub- Learning objectives Teaching strategy Assessment tools
ad topics and
topi
c
Discussion will cover basic At the end of the session students LGIS 1 MCQs as detailed
elements of Health research should be able to ; 1hr contact session earlier.
Proposal (HRP) writing - Clarify means of selecting a topic in AND
Requirement of research proposal writing.

focusing; for research and criteria to be 2-4 parallel classes Assignment based
- Sources of research ideas followed conducted by assessment under
- Criteria for Topic - Explain purpose and sources of Senior faculty 06 Marks.(IA)
selection update information on topic Total share in IA will
- Literature review & - Appreciate elements of be under 10 marks
making introduction
citations- - Explain purpose of statement of
(Purpose, Sources & objectives
ethics) - Narrate necessary components of
- 04 Parts of Introduction methodology section and
(background, update appreciate value of each.
literature, rationale and - Explain parts of questionnaire
35
utility) and types of questions used.
Navigating the Mentor Relationship

36
 Student’s Mentorship Program (IUGRC)
• Student’s Mentorship Program (IUGRC)
• Student’s Research Club RMU (IUGRC)
• Rawalian Student Research Society (RSRS)
Objectives
1. To educate students on various aspects of health research not cleared or covered in class-
room teachings.
2. To supplement or reinforce class room teachings
3. To guide student’s thinking upon their intentions on undertaking health research studies
4. To build capacity in health research of student’s in various years in areas which require
practical or hands on training or small group interactive teachings & training.
5. To register student’s ideas, concepts or hypotheses for undertaking research studies.
6. To undertake student research projects in collaboration & under direct supervision faculty
of RMU (faculty community medicine & public health, faculty of basic & clinical sciences)
7. To promote team work within and across the class
8. To promote research capacity of students working in RSRS thorough involving them in
research teachings
9. To provide opportunities for real life health research for students and faculty of RMU
10. Foster research culture in RMU
37
FUNDAMENTAL REQUIREMENTS FOR UNDERTAKING
HEALTH RESEARCH
 Theoretical teachings
Biostatistics,
Literature review techniques
Research Study Designs
Sampling Techniques
Data Collection Tools development
Art of Data Capturing & Analysis
Research Proposal Writing skills,
 Hands on or Practical Training
Soft Computer Skills
Special Research Packages like SPSS, Epi info
Reference management Software's
Sample size Calculation
 Experiential Research (Research in real life)
 Some level of competency in field of study
PRACTICAL RESEARCH

 Journal club
 Critical reviews

 Role plays

 Group presentation

 Poster presentation

 Annual Research Day

 Symposia /Seminars
43
44
45
RESEARCH TYPES

1. Basic research:
Finding something new not known before necessary to
generate new knowledge and technologies, e.g.
• How did the universe begin?
• How does a crystal melt?
2. Applied research:
Necessary to identify priority problems and to design and
evaluate policies and programs for optimal health care and
delivery, applying the findings of others e.g.
• What is the most efficient and effective vaccine against
Influenza
 SELECTING A RESEARCH TOPIC

How to Choose a Research Topic

➢ Decide which subject interests you the most.
➢ Where do we get our ideas from?
➢ Advisor/ Committee members/ colleagues
➢ Reading literature/publications
➢ Library/internet
➢ Conferences/seminars
➢ Draw inspiration from anywhere you can
➢ Do not undermine your library
➢ Consult the librarian for help with tracking down research papers or writings, and r
the abstracts.
➢ Consult your supervisor at each stage, and in case of difficulty
 KEEP A RESEARCH DIARY
▪ Save Everything in your research diary. That
crumpled note in the wastebasket might be
just the insight you need.
▪ Write down your thoughts as you proceed,
not just those of others. Key each bit of
information, quotation, etc.
▪ Its source, cell # or website, author/title, p.
#Label and date all notes, in each draft.
 HOW TO DEVELOP RESEARCH
QUESTION
• https://youtu.be/nXNztCLYgxc
• https://youtu.be/mrWeLJZydUU
 I
NTRODUCTI
ONTOPHARMACOLOGY

LEARNINGOBJECTI
VES
1.Def
inePhar
macol
ogy
2.Def
ineDr
ugaccor
dingt
oWHO
3.Descr
ibenomencl
atur
eoft
hedr
ug
4.Ci
tedr
ugr
efer
ences(
Phar
macopoei
a)
5.Descr
ibebr
anchesofPhar
macol
ogy

PHARMACOLOGY
Der
ivedf
rom t
woGr
eekwor
ds
Phar
makon-
--
--
--
-dr
ug/
biol
ogi
cal
l
yact
ivesubst
ance
Logos---
--
--
---
--
---
study
Itisthesciencedeali
ngwi
tht
hest
udyofdr
ugsandt
hei
ref
fect
son
biologi
calsystem
Iti
sthestudyofsubstancesthati
nteractwithl
ivi
ngsystemsthrough
chemical
processesespecial
lybybindingtoregulat
orymolecul
esand
ther
ebyacti
vateorinhi
bitbi
ologi
calactiv
iti
esinthebody
DRUG:
Der
ivedf
rom Fr
enchwor
ddr
oguemeani
ngdr
yher
b
Adrugisanysubst
ancethatal
terst
hebiol
ogical
processesi
nthebodyi
na
mannerthatmakesi
tusefulf
ortheprev
enti
on,di
agnosisorcur
eof
di
sease
Adrugi sanysubstanceorproductusedorintendedtobeusedt
omodi f
y
orexplorephysi
ologi
calsyst
emsorpat hol
ogicalstat
esfort
hebenef
itof
therecipi
ent
(W.H.O)
NOMENCLATUREOFDRUG
1.Chemi
cal
Name
I
tisbasedont
hechemi
cal
str
uct
ureoft
hedr
ug
2.Non-
propr
iet
aryname/
gener
icname/
off
ici
alname
I
tist
henamegi
vent
othedr
ugbyacompet
entof
fi
ci
alsci
ent
if
icbody
3.Propr
iet
arynames/
brandnames/
tradename
I
tist
henameassignedbythemanufact
urer

DRUGREFERENCES
Phar
macopoei
a
Iti
sanof fi
cialdocumentpublishedbytheauthori
tyofthe
gov er
nmentoramedi cal
/pharmaceuti
calsoci
etycontaini
ngal
l
i
nf ormati
onaboutt hedrugsregardi
ngthei
rsources,for
mulae,
chemi cal
str
uct ur
e,pharmacokineti
cs,
pharmacody namics,
standardi
zationtests,
doses,etc
 1.USP(
Uni
tedSt
atesPhar
macopoei
a)
2.BP(
Bri
ti
shPhar
macopoei
a)
3.EP (
Eur
opeanPhar
macopoei
a)

BRANCHESOFPHARMACOLOGY
1.Pharmacokinet
ics:(acti
onsoft hebodyonthedr
ug)
Iti
sthebranchofphar macologywhichdeal
swiththest
udyof
absorpt
ion,
dist
ribut
ion,biot
ransfor
mation&excr
eti
onofdr
ugs.
2.Phar
macodynamics:(acti
onsofthedrugont hebody)
I
tist
hebranchofpharmacologywhichdealswiththe
mechani
sm ofacti
onofdrugsat
macromol
ecular
/subcel
lul
ar/
organsystem l
evels.
3.Ther
apeut
ics:
I
tisthear
t&scienceoft
reat
ingdi
seasesmai
nlybydr
ugs
4.Toxi
cology:
I
tisthebranchofphar
macol
ogywhi
chdeal
switht
he
undesi
rabl
eeffect
sofchemi
cal
sonl
ivi
ngsyst
ems
ROUTES OF DRUG
ADMINISTRATION
 CLASSIFICATION

SYSTEMIC LOCAL
Skin topical
Intranasal
Enteral Parenteral Ocular drops
Oral Inhalational Mucosal-throat,
Sublingual Injections vagina, mouth, ear
Rectal Transdermal Inhalational
Intravenous Transdermal
Intramuscular
Subcutaneous
Intra-arterial
Intra-articular
Intrathecal
Intradermal
 Enteral; oral, sub-lingual (buccal),
rectal. Note soluble, enteric coated
or slow release formulations.
 Parenteral; iv, im, sc, id, it, etc.
Different rates of absorption,
different plasma peaks. Note iv
infusions.
 Skin; for local or systemic effect -
note patches.
 Lungs; inhalation; local or
systemic effect?
 Vaginal; (usually local).
 Eye; (usually local).
 FACTORS GOVERNING CHOICE
OF ROUTE
• Condition of the patient- unconscious, vomiting.
• Site of desired action- localized and approachable
or generalized and non approachable.
• Physical & chemical properties of drug-
solid/liquid/gas; solubility, stability, PH, irritancy.
• Rate & extent of absorption from various routes.
• Effect of digestive juices & first pass effect
• Rapidity of the desired response-
emergency/routine.
• Accuracy of dosage.
 ORAL ROUTE
 The most common route of drug administration.
 Drug is given through oral cavity.
ADVANTAGES
 Safe
 Convenient- self- administered,
pain free, noninvasive
and easy to take
 Economical- compared to other parenteral routes
 Usually good absorption- takes place along the
whole length of the GI tract
 ORAL ROUTE
DISADVANTAGES
1. Cannot be used in emergency
2. Irritable and unpalatable drugs- nausea and
vomiting
3. Cannot be used in non-cooperative and
unconscious patients
4. Some drugs are destroyed-Penicillin, Insulin
5. Some drugs are not absorbed-Streptomycin
6. First-pass effect- less bioavailability
7. Food–Drug interactions and Drug-Drug interactions
Dosage forms
Syrup
Capsules, powders
Tablets, spansules
Syrup, emulsion
Suspension, elixirs

Tablets Spansule
Hard- gelatin capsule Soft- gelatin capsule
 SUBLINGUAL/BUCCAL ROUTE
Tab or pellet containing the drug is placed under tongue or
crushed in mouth and spread over the buccal mucosa. nitroglycerine

ADVANTAGES DISADVANTAGES
•Drug absorption is quick •Unpalatable & bitter
•Quick termination drugs
•First-pass avoided •Irritation of oral mucosa
•Can be self administered •Large quantities not
given
•Economical
•Only lipid soluble drugs
can be given
 RECTAL ROUTE
- Drugs that are administered rectally as a suppository
or retention enema
- ex- Diazepam, indomethacin, paraldehyde,
ergotamine
ADVANTAGES DISADVANTAGES
▪Used in children and elderly ▪Inconvenient
patient
▪Absorption is slow and
▪Little or no first pass effect erratic
(ext haemorrhoidal vein)
▪Irritation or inflammation of
▪Used in vomiting or rectal mucosa can occur
unconscious
▪Higher concentrations rapidly
achieved
 PARENTERAL ROUTES
 Direct delivery of drug in to systemic circulation
without intestinal mucosa
Intradermal (I.D.)
Subcutaneous (S.C.)
Intramuscular (I.M.)
Intravenous (I.V.)
Intra-arterial (I.A.)
Intrathecal (I.T.)
Intraperitoneal (I.P.)
Intra - articular
First-pass
metabolism can occur
with orally
administered drugs.
 Advantages Disadvantages
• high bioavailability – Infection
• Rapid action (emergency) – Sterilization.
• No first pass metabolism –Invasive
Suitable for assistance require
–Vomiting &unconsciousness – Pain
– Irritant & Bad taste drugs. – Needs skill
– No gastric irritation – Anaphylaxis
– No food-drug interaction – Expensive.
Dosage form:
Vial or ampoule
 INTRAVENOUS ROUTE
ADVANTAGES
Most common parenteral route
Rapid onset of action, suitable for emergencies
Avoids first-pass metabolism by the liver. (100%
bioavailability)
It is possible to control over the circulating levels of the
drug.
Drugs not absorbed orally or destroyed in GIT by
enzymes can be given by this route
Can be given to unconscious, uncooperative patients
Large quantities can be given
 INTRAVENOUS ROUTE
DISADVANTAGES
Less safe, less convenient, skill required
Costly
Cannot be reversed by strategies such as emesis or
by binding to activated charcoal.
IV injection may cause added adverse reactions by
the too-rapid delivery of high concentrations of drug
to the plasma and tissues like heart, brain etc.
Thrombophlebitis of vein and necrosis of adjoining
tissue if extravasation occurs
Fluid overload
Embolism
 INTRAMUSULAR ROUTE
Large skeletal muscle- Deltoid, triceps, gluteus
maximus, rectus femoris

ADVANTAGES DISADVANTAGES

Local pain and abcess

Absorption reasonably
uniform and faster than Expensive
oral route Infection
Mild irritants can be Nerve damage
given Local hematoma can
First pass avoided occur in anticoagulant
Gastric factors can be treated pt.
avoided
 SUBCUTANEOUS ROUTE

Drug is deposited in loose subcutaneous tissue –

rich nerve supply
Irritant drugs cannot be injected.
Less vascular- slow absorption than IM route
Avoid in shock patient
Only small volume can be injected
Self injected
Depot preparation can be injected- Dermojet, Pellet
implantation, Sialistic and biodegradable implants
 Transdermal
This route of administration achieves systemic effects by application of
drugs to the skin, usually via a transdermal medicated adhesive patch.
The rate of absorption can vary markedly, depending on the physical
characteristics of the drug (lipid soluble) and skin at the site of
application.
 Slow effect (prolonged drug action)
This route is most often used for the sustained delivery of drugs, such
as the antianginal drug nitroglycerin, the antiemetic scopolamine.
the nicotine patches
❑ Site – Upper arm, chest,
abdomen, mastoid region
 First pass effect avoided
 Absorption- increase by oily
base, occlusive dressing,
rubbing preparation
▪ Produce local effect to
▪ Skin (percutaneous) e.g. allergy testing,
topical local anesthesia
▪ Mucous membrane of respiratory tract
(Inhalation) e.g. asthma
▪ Eye drops e.g. conjunctivitis
▪ Ear drops e.g. otitis externa
▪ Intranasal, e.g. decongestant nasal spray
 Advantages Disadvantages
• Mucous membrane of Only few
respiratory system drugs can be
• Rapid absorption used
(large surface area)
•Provide local action
• Minor systemic effect
• Low bioavailability
• Less side effects.
• No first pass effect
Dosage form: aerosol, nebulizer
 Inhalation
Inhalation provides the rapid delivery of a drug across the large
surface area of the mucous membranes of the respiratory tract and
pulmonary epithelium, producing an effect almost as rapidly as with IV
injection.
This route of administration is used for drugs that are gases (for
example, some anesthetics) or those that can be dispersed in an aerosol.
This route is particularly effective and convenient for patients with
respiratory complaints (such as asthma, or chronic obstructive
pulmonary disease) because the drug is delivered directly to the site of
action and systemic side effects are minimized.
Examples of drugs administered via this route include albuterol, and
corticosteroids, such as fluticasone.
 Intranasal
This route involves administration of drugs directly into the
nose. Agents include nasal decongestants such as the anti-
inflammatory corticosteroid.
Desmopressin is administered intranasally in the treatment
of diabetes insipidus; salmon calcitonin, a peptide hormone
used in the treatment of osteoporosis, is also available as a
nasal spray.
The abused drug, cocaine, is generally taken by intranasal
sniffing.
Eye drops
 SKIN - Topical
 Dermal - Oil or ointment for local action
 Antiseptic cream and lotion
 Sunscreen lotion and powders
 No single method of drug
administration is ideal for all
drugs in all circumstances
 DRUG

Dr. Sobia Javaid

MBBS, MCPS (FAMILY MEDICINE),
FELLOWSHIP (SOUTH KOREA),
MPHIL (PHARMACOLOGY)
HANDERSON-HASSELBALCH EQUATION
BIOAVAILABILITY

DR UZMA UMAR
BIOAVAILABILITY
▪ Fraction of unchanged drug reaching the systemic circulation
following administration by any route.

▪ The area under the blood concentration-time curve (AUC) is

a measure of the extent of bioavailability for a drug by any
route
▪ For I/V route------- Bioavailability is unity
▪ For Oral route ------- less than 100% due to 2 reasons
▪ Incomplete extent of absorption
▪ First pass elimination
EXTENT OF ABSORPTION
▪Drug may be incompletely absorbed e.g
▪ Atenolol is too hydrophilic so cannot cross lipid cell
membrane
▪ Acyclovir is too lipophilic so not soluble enough to cross
water layer adjacent to cell
▪ Drug may not be absorbed to P-glycoproteins that
actively pumps the drug back into lumen
▪ Drug may be destroyed by gastric secretions e.g penicilin
insulin
FIRST PASS METABOLISM
FIRST PASS METABOLISM
▪ Effect of first pass elimination on bioavailability is expressed
as extraction ratio
ER = CL LIVER
Q
▪ Systemic bioavailability (F) can also be predicted from extent
of absorption (f) and extraction ratio (ER)
F=f X (1-ER)
▪ e.g morphine is completely absorbed so f is 1 . But ER is
0.67 so (1-ER) IS 0.33 .Hence F is 33%
▪ Drugs with higher Extraction ratio show marked variation in
bioavailability b/w subjects---- d/t variation in hepatic function
and blood flow
▪ First pass effect can be minimised by altering route of
administration e.g sublingual ,transdermal or rectal route
(50%)
Clinical significance of bioavailability
▪ Changes in bioavailability may lead to
▪ Under medication----therapeutic failure
Hazardous for antibiotics ,anticonvulsants
▪ Over medication---toxicity
drugs with high extraction ration can cause toxicity in patients of
cirrhosis
▪ Concept of bioavailabity helps us choose the appropriate
dosage form e.g penicillin , insulin , lidocaine
Drug
Distribution

DR.OMAIMA ASIF
DEMONSTRATOR
Definition

■ It is the process by which a drug reversibly

leaves the blood stream and enters the
interstitial fluid and/or the cells of the tissues
Apparent Volume of Distribution
(Vd)
■ A hypothetical volume of fluid into which a
drug disseminates.
■ Although the Vd has no physiologic or
physical basis.
■ It is some times useful to compare the
distribution of a drug with the volumes of the
water compartments in the body
 Definition of Vd
■ The volume that would accommodate
all the drug (D) in the body if the conc.
(C) throughout was the same as that of
in the plasma.
OR
■ The volume of fluid required to contain
the total amount of drug in the body at
the same concentration as that present
in the plasma.
Formula for Vd

■ It is calculated as the total amount of drug in

the body divided by the concentration of the
drug in plasma

■ Vd = total dose administered = D

plasma concentration C
Distribution of Drugs in Various
Body Compartments
■ 70kg Adult
■ Total Body Water = 42 Liters
■ ICF = 2/3 = 28 Liters
■ ECF = 1/3 = 14 Liters
■ Of the ECF:
Interstitial Volume = 10 Liters
Plasma Volume = 4 Liters
 Plasma Compartment
■ Two possibilities can occur:
■ If a drug has a very large molecular weight
and/or binds extensively to plasma proteins
■ Restricted within the vascular compartment e.
g Heparin & Warfarin
So Vd = 4L
Protein binding
 Extracellular Fluid
■ If a drug has a low molecular weight but is
hydrophilic (lipid insoluble),it can move
through the endothelial slit junctions of
capillaries into the interstitial fluid but cannot
enter into the cells why???
■ e.g Mannitol & Aminoglycosides
■ Therefore Vd = ECF Volume (plasma volume
+ Interstitial fluid volume)
= 4+10 =14 L
Total Body Water

■ If a drug has a low molecular weight and is

hydrophobic (lipid soluble), it can move into
the interstitial fluid as well as can enter cells
■ Thus it distributes into total body water = 42
Liters
■ E.g. Alcohol
Vd More Than Total Body
Water
■ Drugs sequestrated in other tissues
may have Vd much more than total
body water
■ According to formula
Vd=D/Cp
■ So if Cp is very low the value of Vd will
be very high
■ e.g Digoxin, Morphine
Factors affecting
Distribution
 Two Types
■ There are two types of factors that
influence drug distribution.
1. Human Body
(Blood Flow, Organ Size, Capillary
Structure)
1. Drug
( Drug Structure)
 Blood Flow
■ This is an important determinant of the rate
of uptake of drug.
■ Drugs first taken up by highly perfused
tissues High tissue concentrations
■ e.g brain, heart

■ Poorly perfused tissues Low tissue

concentrations
■ e.g bones, fat
Size of the Organ

■ Large Organs take up large amount of drug

by concentration gradient
e.g skeletal muscles
■ Organs of smaller size: distribution of only
small amount of drug into it will raise the
tissue concentration
Capillary Structure

■ In brain, no slit junctions

■ Tight junctions present instead called
BBB
■ Drug must pass through endothelial
cells of capillaries or actively
transported.
Drug Structure

■ Drugs with MW > 1000 D are poorly

distributed e.g ?
■ Hydrophobic ?
■ Less hydrophobic readily cross BBB
and placenta
■ Hydrophilic?
Other Factors

Fat: Lean Body Mass Ratio:

Those people having high Fat:Lean
body mass ratio will have less distribution of
the drug
Pregnancy:
3 Fs play pivitol Role
1. Fluid
2. Fat
3. Fetus
Pathological States

■ Congestive Heart Failure: (alteration of body

water)

■ Cirrhosis of Liver: Decreased synthesis of

plasma proteins

■ Uremia: Accumulation of Metabolites that

displace drugs from binding sites
 Objectively Structured Performance Evaluation
(OSPE)

Unobserved Station No 2

Marks:5
For Candidate.
Task:
Carefully answer the following question.
■ Write down the formula of volume of distribution of drug.
■ Using the formula solve the following:
■ You administered 500mg of a drug to a 70 kg adult, after
sometime plasma conc was 200mg.
PLASMA PROTEIN BINDING
Plasma Protein Binding
■ After absorption, the drug circulates in the
blood either in the free form or bound to
plasma proteins. This binding is reversible.
■ These drugs are inert in bound form
(Pharmacologically inactive)
■ Most drugs possess physicochemical affinity
for plasma proteins.
■ Plasma protein binding is > 80%. Effects in
humans begin at 40 to 60 minutes, peak at 2
to 4 hours, and gradually return to baseline
over 6 to 8 hours.
Cont..

■ Only the free form is pharmacologically active

■ Bound form of the drug is not easily

metabolized or excreted

■ So plasma proteins act as a reservoir or

temporary storage place
Types of Drug-Protein Binding
❑ Reversible:
• Weak chemical bonds such as hydrogen
bonds or van der Waals forces
• Occurs to most drugs
❑ Irreversible:
• Covalent chemical bonds
• Accounts for certain toxicities of drugs
and carcinogens
e. g. high doses of acetaminophen
Major Drug-Binding Proteins in
Plasma
■ Albumin: binds mostly to acidic drugs
■ a1-acid glycoprotein: binds mostly to basic
drugs
■ Lipoproteins: binds mostly to neutral drugs
Characteristics

■ Pharmacologically inactive
■ Reversibly bound
■ PP as reservoirs if conc drug dissociates
■ Cannot be metabolized easily
■ Longer duration of action
■ Low Vd
■ May displace or get displaced
■ Increase distributional delay
Factors affecting PPB
■ DRUG RELATED FACTORS
i. Physiochemical characteristics of the drug.
ii. Concentration of drug in the body.
■ PROTEIN/TISSUE RELATED FACTORS
i. Concentration of protein/binding component
ii. Number of binding sites on the protein
■ DRUG INTERACTIONS
■ PATIENT RELATED FACTORS
▪ i. Disease states
DRUG RELATED FACTORS
■ Lipophilicity is the most desirable physiochemical
parameter that is perquisite for protein binding to
occur.
■ Also an increase in the lipid content of drug moiety
eventually enhances the rate as well as extends of
protein binding process.
■ Concentration of drug in the body:
Alteration in the concentration of drug substance as
well as the protein molecules or surfaces subsequently
brings alteration in the protein binding process.
PROTEIN/TISSUE RELATED
FACTORS
■ Concentration of protein/binding component:
■ Human serum plasma proteins constitute the major
portion of the plasma proteins, a large number of
drugs undergo an extensive binding with them.
■ Number of binding sites on the protein:
■ Albumin not only possesses large number of binding
sites but also has greater potential of carrying out
binding process.
■ Numerous drug exhibit multiple site binding with
albumin molecules in plasma like fluocloxacillin,
ketoprofen, indomethacin etc .
 PATIENT RELATED FACTORS
■ Disease states:
■ Chronic Liver Disease:
■ Hypoalbuminemia causes decrease
PPB of many drugs bound to albumin e.
g phenytoin, salicylates
■ Increased levels of bilirubin may
compete with drugs for PPB
Cont..
■ Renal Functions
■ Chronic Renal Failure:
■ Decrease in PPB caused by inc urinary
loss of proteins.
■ Retention of metabolites which
competes with drugs for binding sites e.
g digoxin, phenytoin.
LETS DO ACTIVITY

CLINICAL SIGNIFICANCE
■ Prolonged action of drug.
■ Interpretation of measured drug conc.
■ When two drugs are administered a the
same time one will replace other and
free form will be available
■ Too strong binding can cause
irreversible binding and toxicity
■ Drugs will bind with the PP according
to their affinity, when two drugs
Clinical Significance

1. When TWO drugs are given, each with a

high affinity for plasma protein, they
compete for the available binding sites
 By Dr. Arsheen Arshad
Pharmacology department
 Learning objectives
 Define pharmacokinetics.
 Explain cell membrane structure and
physiology.
 Discuss different mechanisms of drug
transport.
 Define drug absorption.
 Describe drug based and biological factors
affecting absorption.
 PHARMACOKINETICS
Is the quantitative study of drug
movement in, through and out of
the body.
All pharmacokinetic processes
involve the transport of the drug
across the biological membrane.
 Cell Membrane (biological
membrane)
 Lipid bilayer (about 100A° thick)
 Phospholipids
a. Phosphates (hydrophilic)
b. Fatty acids (hydrophobic)
 Lipid soluble and very very small molecules can pass
through cell membrane.
 Highly polar and large molecules can not pass
through membrane.
 Embedded in the matrix are
➢Extrinsic or peripheral proteins:
 Loosely bound to surface of membrane
 cell surface identity marker (antigens)

➢Intrinsic or integral proteins:

 penetrate lipid bilayer, usually across whole
membrane.(pumps/ channels).
 Drugs are transported across the
membrane by:
1. Passive transport:
a. Simple diffusion
b. Filtration/ aqueous diffusion
c. Bulk flow
2. Active transport:
a. Primary active transport
b. Secondary active transport
c. Endocytosis:
1. Phagocytosis
2. Pinocytosis
3. Transcytosis
3. Specialized transport:
Involving facilitated diffusion
 Simple diffusion
Most of the drugs are absorbed by simple diffusion ,
which is the movement of molecules down the
concentration gradient i.e. from higher
concentration to lower concentration.
 This type of transport occurs mostly for the lipid
soluble drugs.
 Non-specific:
This type of transport is non-specific i.e. no carrier
proteins are required.
 Energy expenditure:
no energy is required for this type of transport.
 Filtration
 Filtration involves the aqueous channel or
pores through which hydrophilic drugs can
pass. Filtration occurs in the jejunum and
proximal tubules of kidneys. It is absent in
the stomach and the lining of the urinary
bladder.
 Only certain ions like Na+ and drugs of low
molecular weight , like ethanol and glycerol
can undergo filtration.
 Bulk flow
 The drug in this process passes through the pores between
capillary endothelial cells. The passage is independent of
water and lipid solubility.
 Bulk flow is the phenomenon mostly seen with the intra
muscular and subcutaneous injections. Drug is injected in
bulk form into the muscle. Drug molecules along with the
aqueous medium pass through the pores of endothelium ,
and diffuse into the blood.
 This type of transport is independent of pH and pKa. Bulk
flows does not occur in brain because of absence of pores.
 However , bulk flow is dependent on the flow , more the
blood flow , more rapid is the absorption. This is why the
area is rubbed after intra muscular injections to increase
the blood flow.
 Active Membrane Transport
 Active membrane transport is for the drugs which cannot
cross the lipid membrane and require transport proteins.
Their structure is similar to the endogenous substances
undergoing active transport like amino acids , sugars ,
neurotransmitters , which have the transport proteins.
 Active transport is the carrier mediated transport.
 The drug moves against the concentration gradient. Energy
in the form of ATP is required for the process to occur.
 Different drugs bind different proteins , thus their
absorption is selective from different areas , as well as their
distribution.
 Some drugs directly affect the brain like the Levo
Dopa , which utilize amino acid transporting
mechanism. Other examples include methyl dopa
for hypertension and fluorouracil which is
anticancer drug.
 Active transport mechanism is saturable and can
be inhibited by competing drugs.
 Primary Active Transport
When the substance moves against the
concentration gradient by the expenditure
of energy , the process is called primary
active transport .
 Secondary Active Transport
 When the substance moves against the
concentration gradient by the energy stored
by a substance moving down the
concentration gradient , the process is
called secondary active transport.
 Pinocytosis
 Pinocytosis , or cell drinking , requires
expenditure of energy. Fat soluble vitamins ,
protein molecules and folic acid enter the
cells by this process.
 Facilitated Transport
 Facilitated transport involves the drugs moving down
the concentration gradient by the help of transport
proteins.
 No energy expenditure is required.
 This type of transport is also specific and saturable.
 The main objective is that lipid insoluble drugs
become lipid soluble by combining with the carrier.
E.g . Iron binds with apoferritin and certain
catecholamines enter the nerve cells by this process.
BIOTRANSFORMATION
Dr. Zunera Hakim
Learning outcomes
At the end of the session, the learner will be able to;

1 Define biotransformation/metabolism of drugs

2 Describe the outcomes of biotransformation

3 Recognize the significance of biotransformation

4 Enlist & describe types of drug metabolizing

reactions

5 Identify the factors affecting biotransformation

 BIOTRANSFORMATION

Chemical alteration that a drug molecule

undergoes in a living organism with a
consequent change in its solubility & activity
Drug metabolism
OUTCOMES OF BIOTRANSFORMATION
Activity
1. Active drug to inactive metabolite
2. Active drug to active metabolite
3. Active drug to toxic metabolite
4. Inactive drug (prodrug) to active metabolite

Solubility
Lipophilicity to hydrophilicity
OUTCOME OF BIOTRANSFORMATION
• Phenobarbitone
Inactive
• Phenytoin
Active
• Morphine to morphine 6 glucuronide
drug Active
• Diazepam to nordiazepam
• Halothane to trifluoroacetic acid
Toxic
• Paracetamol to NAPQI

Inactive • Levodopa to Dopamine

Active
drug • Enalapril to enalaprilat
SIGNIFICANCE OF BIOTRANSFORMATION

Lipophilic Hydrophilic Excretion

metabolite
drug

Biotransformation
SITES OF BIOTRANSFORMATION
Alprazolam
Suxamethonium
Prostanoid

Cyclosporin A Penicillin
Chlorpromazin
e
Propanolol
Cephalothin
Morphine
Imipenem
Lidocaine
TYPES OF BIOTRANSFORMATION

2
1. Non-enzymatic biotransformation
2. Enzymatic biotransformation
a) Microsomal
b) Non-microsomal
NON-ENZYMATIC (HOFFMAN ELIMINATION)

Spontaneous, non-enzymatic molecular rearrangement of

drug in body

Examples

1. Atracurium converted to laudanosine

2. Hexamine converted into Formaldehyde
ENZYMATIC BIOTRANSFORMATION

NON-MICROSOMAL
Monoamine oxidase involved in
metabolism of catecholamine
Biotransformation
carried out by
enzymes Alcohol dehydrogenase responsible for
present in metabolism of ethanol into acetaldehyde
mitochondria
and cytosol
 MICROSOMAL
• Enzymes present within lipophilic
membranes of endoplasmic
reticulum (microsomes)
• Smooth ER is concerned with
biotransformation
1. Cytochrome P450*
• After isolation and putting through
2. Flavin Mono-oxygenase homogenization and fractionation,
vesicles are obtained, known as
3. Glucuronosyl transferase microsomes
CYTOCHROME P450 (CYP 450)
Superfamily of heme containing microsomal
enzymes

Present in many tissues with liver having

the
highest concentration

Component of mixed function oxidase (MFO)

system along with

• NADPH
• Molecular oxygen
 CYP 450
• 50 individual CYPs identified with 17 families & sub families

• CYP1A2, CYP2A6, CYP2B6, CYP2C9,

CYP2C19,CYP2D6, CYP2E1 and CYP3A4
10%

CYP Cytochrome P 20%

CYP3A4 3 Family 70%

A Sub-family
4 Isoform
 CYTOCHROME P450
• A single CYP isozyme can metabolize a large number of structurally
diverse drugs
• A single drug may be a substrate for one or more than one CYP isozyme
• The activity and expression of CYP in tissue is influenced by :
❖ Genes encoding CYP enzymes
❖ Age
❖ Gender
❖ Diet
❖ Environmental exposure
❖ Drugs
 PHASES
OF
BIOTRANSFORMATION
 PHASES OF ENZYMATIC
BIOTRANSFORMATION
DRUG

PHASE-I PHASE -II

water soluble & polar metabolite

EXCRETION (urine & bile)

PHASE -I OF BIOTRANSFORMATION
PHASE-I
• Non- Synthetic

• Introduction or unmasking of a functional

group (-OH,-SH,-COOH,-NH)

REACTIONS
.
• Oxidation
CYP 450 • Reduction
• Hydrolysis
CONSEQUENCES OF PHASE -I
• Inactive
Activity* • Active
• Toxic

Solubility • Increase hydrophilicity/

polarity

• If sufficiently polar
Excretion/ excreted
Fate • If not, metabolite
undergoes phase -II
PHASE-I REACTION
 PHASE –II REACTIONS
• Synthetic
• Conjugation reactions
Transferase
(endogenous substances)
• Substrates --------parent drug, metabolite of phase -I

Phase –I is generally followed by Phase –II, however there is

exception when phase-II is followed by phase-I
 PHASE-II REACTIONS
Type of Endogenous Reactant Transferase (Location) Examples
Conjugation
Glucuronidation UDP-glucuronic acid UDP-glucuronyl Morphine,
transferase (microsomes) acetaminophen

Acetylation Acetyl – CoA N-Acetyl transferase Sulfonamides,

(cytosol) isoniazid
Glutathione Glutathione GSH-S-transferase Ethacrynic acid,
conjugation (cytosol, microsomes paracetamol
Glycine Glycine Acyl-CoA glycine Salicylic acid,
conjugation transferase (mitochondria) benzonic acid
Sulfate Phosphoadenosyl- Sulfotransferase (cytosol) Acetaminophen,
conjugation Phosphosulfate methyldopa
Methylation S-Adenosylmethionine Transmethylase (cytosol) Dopamine,
epinephrine
PHASE –II REACTIONS
 CONSEQUENCES OF PHASE-II

Activity Solubility Fate/Excretion

Inactive Hydrophilicity
Active
Minoxidil to mioxidil sulphate
Morphine to morphine glucuronide

Toxic/reactive
PHASE –II preceed PHASE-I
FACTORS AFFECTING
BIOTRANSFORMATION
 • Genetic polymorphism
Genetic • Race/ethnicity
• Specie
• Age
• Gender
Intrinsic • Pathological states
BIOTRANSFORMATION
FACTORS AFFECTING

• Commensal Gut Microbiota

• Drug-drug interactions
• Route of administration
Extrinsic • Environmental effects
• Diet
• Social habits
PLASMA HALF LIFE

Dr. Attiya Munir

AP, HOD
Pharmacology, RMU
 DEFINITION

 “The time it takes for the plasma concentration of a

drug to be reduced to 50 % of its initial value after
the peak has been achieved.”
OR
 “The time required to change the amount of drug in
body by one half during elimination(or during a
constant infusion)”
 FORMULA FOR HALF LIFE

t1/2=log2/k
As,
log2=0.693
k=CL/V
so,
t1/2=o.693×V/CL
 EXAMPLE

TIME: 0HR 1HR 2HR 3HR 4HR

CONC. 100 50 25 12.5 6.25

 EXAMPLES

 Penicillin-G 30mins
 Doxycyclin 20hrs
 Digoxin 40hrs
 Warfarin 44hrs
 Diazepam 30hrs
 Aspirin 4hrs
 FACTORS AFFECTING HALF LIFE

 Volume of distribution
 Clearance
 Plasma protein bounding
 Plasma half life is not an exact index of drug
elimination.
 Nearly complete drug elimination occurs in 4-5 half
lives.
1st half life-50%drug is eliminated
2nd half life-75%(50+25)
3rd half life-87.5%(50+25+12.5)
4th half life-93.75%(50+25+12.5+6.25)
 IMPORTANCE OF PLASMA HALF LIFE

 Clearance
 DOA
 Frequency of dosing
 Selection of the drug
 Prevents inadequate and excess administration
 Steady state concentration
 STEADY STATE CONCENTRATION

 “when a drug is repeated at relatively short intervals, it

accumulates in the body until elimination balances input.”

Cpss=dose rate/CL
Dose rate=target Cpss x CL
After oral administration, only a fraction F of the drug is
available. so,
Dose rate=target Cpss x CL/F

 Drug reaches steady state concentration after 4-5 half lives.

 Css=Ro/CL
 If we administer a drug again & again before the time
drug gets eliminated plasma levels will start to raise,
steady state conc. achieved…

 For drugs eliminated by

First order kinectics - t1/2 remains constant as V
and CL donot change with dose
Zero order kinectics - t1/2 increases with the
dose as CL decreases with dose
 FIRST ORDER ELIMINATION

 The rate of elimination occur is directly proportional to

the concentration of the drug.

 The higher the concentration, the greater the amount of

drug eliminated per unit time.

 The result is that the drug’s concentration in plasma

decreases exponentially with time. (50% of every half
life)

 A constant FRACTION of a drug is eliminated per unit

time.
 V=RATE OF METABOLISM=Vmax[C]/Km+[C]
 IF C<<<Km THEN…

 V=RATE OF METABOLISM=Vmax[C]/Km

 Thus V α C

 Most of the drug in therapeutic doses follow 1st order

kinectics.
 ZERO ORDER ELIMINATION

 Rate of elimination is constant regardless of

concentration.

 As a result, the concentration of theses drugs in plasma

decrease in a linear fashion over time.

 Ethanol, Phenytoin, Aspirin

 A constant AMOUNT of a drug is eliminated per unit

time.
 100g--50g—0g
Drug elimination and
excretion
Dr. Rubina Kouser
Elimination of drugs
 Elimination is irreversible removal of drug from the body.
 Once a drug enters the body, the process of elimination begins.
 It involves:
1. Biotransformation(drug metabolism)
2. Excretion

 Together, these elimination processes decrease the plasma

concentration exponentially.
 That is, a constant fraction of the drug is eliminated in a given unit
of time.
Drug excretion

 Excretion is removal of intact drug from the body.

 Nonvolatile drugs are mainly excreted by renal excretion
 A process in which drug passes through the kidney to the bladder and ultimately
into the urine.
 Volatile drugs such as gaseous anesthetics or drugs with high volatility are
excreted via the lungs into expired air.
 Other pathways for drug excretion are excretion of the drug into
1. Bile
2. sweat
3. saliva
4. milk
5. or other body fluids
Biotransformation

 The process by which the drug is chemically converted in the body to a

metabolite.

 It is usually as enzymatic process.

 In which the lipid soluble agents are first metabolized into more polar
hydrophilic substances in the liver by two sets of reactions called:
1. Phase 1 reaction
2. Phase 2 reaction
Drug clearance by the kidney

 Drugs must be sufficiently polar to be eliminated from the body.

 Removal of drugs from the body occurs via a number of routes;

 the most important is elimination through the kidney into the urine.

 Patients with renal dysfunction may be unable to excrete drugs and are at
risk for drug accumulation and adverse effects.
Renal elimination of drugs

 Renal excretion is a major root of elimination for many drugs.

 A drug passes through several processes in the kidney before elimination:

1. glomerular filtration

2. active tubular secretion

3. and passive tubular reabsorption.

Glomerular filtration

 It is a passive process by which small molecules and drugs are filtered through
the glomerulus of the nephron.
 Drugs enter the kidney through renal arteries, which divide to form a
glomerular capillary plexus.
 Free drug (not bound to albumin) flows through the capillary slits into the
Bowman space as part of the glomerular filtrate.
 The glomerular filtration rate (GFR) is normally about 120 mL/min/1.73m²
but may diminish significantly in renal disease.
 Lipid solubility and pH do not influence the passage of drugs into the
glomerular filtrate.
 However, variations in GFR and protein binding of drugs do affect this
process.
Proximal tubular secretion

 Secretion primarily occurs in the proximal tubules by two energy-requiring

active transport systems:
 One for anions (for example, deprotonated forms of weak acids) and
 One for cations (for example, protonated forms of weak bases).
 Competition between drugs for these carriers can occur within, for example:
1. probenecid( a weak acid) competes for the same system as penicillin
decreasing the rate of penicillin excretion.
 [Note: Premature infants and neonates have an incompletely developed
tubular secretory mechanism and, thus, may retain certain drugs in the
blood.]
Distal tubular reabsorption

 As a drug moves toward the distal convoluted tubule, its concentration

increases and exceeds that of the perivascular space.
 The drug, if uncharged, may diffuse out of the nephric lumen, back into the
systemic circulation.
 Generally, weak acids can be eliminated by alkalinization of the urine
 whereas elimination of weak bases may be increased by acidification of the
urine.
 This process is called "ion trapping."
1. For example, a patient presenting with phenobarbital (weak acid)
overdose can be given bicarbonate, which alkalinizes the urine
and keeps the drug ionized, thereby decreasing its reabsorption.
Drug excretion via other routes

 Drug excretion may also occur via the intestines, bile, lungs, and breastmilk,
among others.
 Drugs that are not absorbed after oral administration or drugs that are
secreted directly into the intestines or into bile are excreted in the feces.
 The lungs are primarily involved in the elimination of anesthetic gases (for
example, desflurane).
Drug excretion by other routes

 Elimination of drugs in breast milk may expose the breast-feeding infant to

medications and or metabolites being taken by the mother and is a potential
source of undesirable side effects to the infant.

 Total body clearance and drug half-life are important measures of drug
clearance that are used to optimize drug therapy and minimize toxicity.
Clearance

 Clearance estimates the volume of blood from which the drug is cleared per
unit time.
 Total clearance is a composite estimate reflecting all mechanism of drug
elimination and is calculated as follows:
𝑉𝑑
𝐶𝐿 = 0.693 ×
𝑡1
2

Where t1/2 is the elimination half-life, Vd apparent volume of distribution and

0.693 in the natural log constant.

Drug half life is often used as a measure of clearance because for many drugs Vd
is a constant.
Total body clearance

 The total body (systemic) clearance, CLioel, is the sum of all clear-ances from
the drug-metabolizing and drug-eliminating organs.
 The kidney is often the major organ of excretion.
 The liver also contributes to drug clearance through metabolism and/or
excretion into the bile.
 Total clearance is calculated using the following equation:
 CLTotal = CLHepatic + CLRenal + CLpulmonary + Clothers

 where CLhepatic + CLrenal are typically the most important.

Renal drug excretion
 Renal clearance may be considered as the ratio of the sum of the glomerular
filtration and active secretion rate less the reabsorption rate divided by the
plasma drug concentration

𝐹𝑖𝑙𝑡𝑟𝑎𝑡𝑖𝑜𝑛 𝑟𝑎𝑡𝑒 + 𝑆𝑒𝑐𝑟𝑒𝑡𝑖𝑜𝑛 𝑟𝑎𝑡𝑒 – 𝑅𝑒𝑎𝑏𝑠𝑜𝑟𝑝𝑡𝑖𝑜𝑛 𝑟𝑎𝑡𝑒

 CLr = 𝐶𝑝
INTRODUCTION TO HEALTH RESEARCH

Dr. Rizwana Shahid

Assistant Professor Community Medicine
Assistant Director Medical Education
Rawalpindi Medical University, Rawalpindi
The most complete gift of God
is a life based on knowledge
 Learning Objectives
By the end of this lecture, students should
be able to:
1. Define research
2. Elaborate health system research
3. Discuss the scope of health system
research
4. Illustrate the types of health research
5. Introduce various search engines
6. Describe attributes of a research
question
 WHAT IS RESEARCH?

• Research refers to a search for

knowledge
• Research means a scientific and
systematic search for pertinent
information on a specific topic

• The purpose of research is to

discover answers to questions
through the application of scientific
 Health System Research
HSR enables us to:
• Understand and improve how
societies organize themselves in
achieving collective health goals
• Find out ways how different actors
interact in the policy and
implementaion processes to
contribute to policy outcomes.
 Health System Research
• HSR gives us :
• “comprehensive picture of how
health systems respond and adapt to
health policies, and how health
policies can shape − and be shaped
by − health systems and the broader
determinants of health”.

Gilson (ed)2012
 Health Systems Research
• Systematic investigation and
evaluation of the functioning and
development of health services and
their inter-relationship with health
related factors
• It is integral at all levels of health
care delivery
 HSR
• HSR is not:
• • Clinical or basic science
• • Only rooted in health economics
or focused on financing issues
(though both important)
• • Focused on disease distribution,
causes and interventions (but rather
generic organisational and
societal‘structures)
 4 Steps of HSR
• Identify research [research question]

• Design study

• Ensure quality

• Follow ethical principles

 WHAT IS RESEARCH ?

“RESEARCH IS AN
ART
OF SCIENTIFIC INVESTIGATION ”
 Types of Research
Basic research
“Gathering knowledge for knowledge’s sake is
termed ‘pure’ or ‘basic’ research.”

Applied research aims at finding a solution for an

immediate problem facing a society or an industrial/
business
Organization
 Types of research
• (Descriptive research studies) To
describe accurately the characteristics of
a particular individual, situation or a
group

• (Analytical research studies) To

determine the association between
exposure and outcome
 What is a good research
question?

FINER
The characteristics of a good research
question, assessed in the context of the
intended study design, are that it be
feasible, interesting, novel, ethical, and
relevant (which form the mnemonic
FINER;
 Search engines
– Google scholar
– PubMed
– Cochrane
 Scope of Health System
Research
• Health care financing
• Organization & management of research
into healthcare delivery systems
• Policy making
• Intra and inter-sectoral coordination
• Designing healthcare delivery
• Community participation
Steps in HSR
A good research proposal is
based on scientific facts
and on the art of clear
communication
 Top 10oidableReasons Manuscripts
Av
Rejected
1. Wrong format, preparation
2. Disorganized study design
3. Defective tables, figures
4. Poor organization throughout, writing, spelling
5. No hypothesis or problem statement
6. No or insufficient conclusion
7. Over interpretation of results
8. Article unfocused, too verbose and long
9. Inappropriate statistical methods; methods not
sufficient to repeat study Pierson DJ, Respiratory Care 49(10), 2004

10. Poorly written abstract/title Byrne DW, Publishing Medical Research Papers, Williams and Wilkins,
1998
 Some Guidelines

• Write simple grammatically correct

sentences
• Brevity is the best practice
• Avoid irrelevant details
• Show the draft to colleagues
• Read final draft carefully
• Typographical and grammatical mistakes
give bad impression
• Check tables and figures (Captions, size,
THANK YOU!
 Behavioural Sciences

Prof Asad Tamizuddin Nizami

MBBS MCPS (Medical Education) FCPS (Psychiatry)
Fellowship in Health Systems Research (UK)
Fellowship in Old Age Psychiatry (UK)

Professor of Psychiatry
Rawalpindi Medical University

Chairman Institute of Psychiatry

Benazir Bhutto Hospital Rawalpindi

Member Federal Mental Health Authority Islamabad

Member Faculty of Psychiatry College of Physicians & Surgeons Pakistan
Vice President Pakistan Psychiatric Society
Why do you want to become a Doctor ?

Responses %
Ability to earn money and the good social standing in 10%
society
Eradicating illnesses and finding a cure for various 12%
diseases
Medical profession is the noblest and the most respected 15%

Students ambition or their parent’s dreams 17%

Inspiration to be of service to the humanity, the nation, 46%

the country and religion
 Am I Fulfilling My Dream?
I had always wanted to be a doctor … since when …. I do not remember
I believe it was engrained on my heart and my fate from the day of my
birth and now I’m a student of a highly ranked Medical University.

The first few days were enchanted. The new books, my overall, the
campus building, big classrooms, the study plan, the introductory
lectures, everything seemed just perfect.

As the days passed, the schedule of sub stages, stages, modular exam
came up. While trying to memorize the nerve supply of upper limb, I
forget the physiology lecture that I memorized last week.

For past few days, I have developed a constant headache. I stay and
study in my room all the time, but I feel as if I’m getting dull. I can’t sleep
properly. My parents are worried about my irritable attitude towards
them. I now think ….. am I fulfilling my dream? …. my mental and
physical health ? What do I do?
Behavioural Sciences ?

HUMAN BEHAVIOUR
Behavioural Sciences
 Behaviour Sciences

Psychiatry

Mental Health
Psychology
Sociology
Anthropology
Global Distribution Of Health Burden

• Major Depression 4.2

 Predicted Global Impact in 2020

1. Ischaemic heart disease

2. Major Depression
Rank
order of 3. Road traffic accidents
disease
burden 4. Cerebrovascular disease
5. Chronic obstructive pulmonary disease
6. Lower respiratory infections

World Bank’s Burden of Disease Estimates 1996: Murray & Lopez eds. The global burden of disease. Boston, MA:
Harvard University Press for the WHO.
Almost half of the world's population live in a country
where, on an average, there is one psychiatrist or
less to serve 200,000 people or more.
Islamabad …… July 2019
Teaching Structure

First Year – Behavioral Sciences

Second Year – Behavioral Sciences

Third Year – Psychiatry & Mental Health

Fourth Year – Psychiatry & Mental Health

Final Year – Psychiatry & Mental Health

Introduction to Behavioral Science

• Bio Psycho Social Model

• Communication Skills
• Counseling
• Informational Care
• Breaking Bad News
• Conflict Resolution
Medical Ethics

• Ethical Dilemmas
Use of behavioral science principles in …
Behavioral Sciences in Health & Disease

Death & Dying

Stigma to Mental Illnesses

Use of Behavioral Sciences in clinical situations
and settings
Behavioral Science Interventions

• Stress and its management

Behavioral Sciences Examination

• Each Module will have Two Interactive Sessions on

Behavioral Sciences

5 to 10 MCQs
Faculty for teaching Behavioral Sciences

Prof Asad Tamizuddin Nizami

Dr Munir Ahmed
Dr Muhammad Kashif
Dr Mahmood Jafri
Dr Azeem Khan
Dr Saadia Yasir
Dr Zarnain Umar
Dr Mehboob Ali Shah
Institute of
Psychiatry
 Medicine is a profession
incorporating science and
evidence base

But

‘the art of being a physician’

 Thank you

ioprmu@gmail.com
 27/02/2021

Clinical Leadership and

Professionalism for
Medical Students
DR ARSALAN MANZOOR MUGHAL

2/27/2021 LEADERSHIP & PROFESSIONALISM - DR. ARSALAN MANZOOR MUGHAL

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Objectives
Define Clinical Leadership

Differentiate between management and leadership

Describe your leadership style

Develop leadership skills

2/27/2021 LEADERSHIP & PROFESSIONALISM - DR. ARSALAN MANZOOR MUGHAL

“ Setting, inspiring and promoting

values and vision, and using their
clinical experience and skills to
ensure the needs of the patient are
the central focus in the
organization's aims and delivery “

ABC of Clinical Leadership

2/27/2021 LEADERSHIP & PROFESSIONALISM - DR. ARSALAN MANZOOR MUGHAL

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 27/02/2021

What are the differences between

Management and Leadership?
Reflection Exercise

2/27/2021 LEADERSHIP & PROFESSIONALISM - DR. ARSALAN MANZOOR MUGHAL

2/27/2021 LEADERSHIP & PROFESSIONALISM - DR. ARSALAN MANZOOR MUGHAL

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2/27/2021 LEADERSHIP & PROFESSIONALISM - DR. ARSALAN MANZOOR MUGHAL

What is your leadership

style ?
ACTIVITY

2/27/2021 LEADERSHIP & PROFESSIONALISM - DR. ARSALAN MANZOOR MUGHAL

4
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Liessez-
Authoritarian Democratic
Faire

2/27/2021 LEADERSHIP & PROFESSIONALISM - DR. ARSALAN MANZOOR MUGHAL

Newer Leadership Styles

2/27/2021 LEADERSHIP & PROFESSIONALISM - DR. ARSALAN MANZOOR MUGHAL

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Action Centered Leadership

2/27/2021 LEADERSHIP & PROFESSIONALISM - DR. ARSALAN MANZOOR MUGHAL

Transformational Leadership
idealized influence (role model)
inspirational motivation (vision)
intellectual stimulation (creativity)
Individual consideration (empathy)

Change through empowerment and development of

followers
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NHS Leadership Qualities

2/27/2021 LEADERSHIP & PROFESSIONALISM - DR. ARSALAN MANZOOR MUGHAL

Can leadership be learnt?

Trait theory- Innate, “Born Leader”, “Great
Man”, Y-Chromosome
“an observable, learnable set of practices’.
Posner and Kouzes (1996)
Leadership Competency- an intended and
defined outcome achievable through learning

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Being a Leader
ACTIVITY

2/27/2021 LEADERSHIP & PROFESSIONALISM - DR. ARSALAN MANZOOR MUGHAL

Mission, Strategy and Vision

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8
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Knowing your
institute- Vision

2/27/2021 LEADERSHIP & PROFESSIONALISM - DR. ARSALAN MANZOOR MUGHAL

Knowing your
institute- Mission

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Leadership in Group Work

2/27/2021 LEADERSHIP & PROFESSIONALISM - DR. ARSALAN MANZOOR MUGHAL

Medical
Professionalism

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 27/02/2021

Objectives
Define Medical Professionalism

Describe attributes of the healer and the professional

Discuss the social contract of the medical profession

2/27/2021 LEADERSHIP & PROFESSIONALISM - DR. ARSALAN MANZOOR MUGHAL

Professionalism is demonstrated through a

foundation of clinical competence,
communication skills, and ethical and legal
understanding, upon which is built the
aspiration to and wise application of the
principles of professionalism: excellence,
humanism, accountability, and altruism.
MEDICAL DEFINITION
Stern D.T. (ed.). Measuring Medical Professionalism. New York, Oxford
University Press, 2005, p. 19.

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Refection

Can Professionalism be taught?

2/27/2021 LEADERSHIP & PROFESSIONALISM - DR. ARSALAN MANZOOR MUGHAL

Time Management

Stress Management

Linking
Professionalism
Values
to Specific
Communication Skills

Behaviors

Emotional Intelligence

2/27/2021 LEADERSHIP & PROFESSIONALISM - DR. ARSALAN MANZOOR MUGHAL

13
CELL INJURY,
CELL DEATH
&
ADAPTATIONS
 An Overview
Introduction to Pathology

Overview of Cellular Response to Stress

and Noxious Stimuli

Cellular Adaptations to Stress

Hypertrophy
Hyperplasia
Atrophy
Metaplasia

Overview of Cell Injury and Cell Death

Causes of Cell Injury

 An Overview…. contd
The Morphology of Cell and Tissue Injury
Reversible Injury
Necrosis
Patterns of Tissue Necrosis
Sub cellular Response to Injury
Mechanisms of Cell Injury
Depletion of ATP
Damage to Mitochondria
Influx of Calcium
Accumulation of Oxygen- Derived Free Radicals
( Oxidative Stress)
Defects in Membrane Permeability
Damage to DNA and Proteins
 An Overview….. contd
Examples of Cell Injury and Necrosis
Ischemic and Hypoxic Injury
Ischemia – Reperfusion Injury
Chemical (Toxic) Injury
Apoptosis
Causes of Apoptosis
Mechanisms of Apoptosis
Examples of Apoptosis
Intracellular Accumulations

Pathologic Calcification

Cellular Aging
INTRODUCTION
TO
PATHOLOGY
 DEFINITION OF PATHOLOGY
 Pathology is the scientific study of disease

 Pathos means - suffering

Logos means – study

 Pathology is thebridging discipline involving both basic

science and clinical practice and is devoted to the study of
the structural and functional changes in cells, tissues, and organs
that underlie disease.

 By the use of different techniques pathology attempts to explain

the whys and wherefores of the signs and symptoms manifested
by the patient while providing a sound foundation for rational
clinical care and therapy

 The ultimate goal of pathology is the identification of the causes

of disease, a fundamental objective leading to successful therapy
and disease prevention
 AIM OF PATHOLOGY LAB

Aim of pathology lab is to deliver accurate

and timely data to assist in the diagnosis
of disease and to monitor response to
treatment.
 LEARNIING PATHOLOGY

Pathology is best learnt in two ways:

I. GENERAL PATHOLOGY:
General Pathology is concerned with the basic reactions of cells
and tissues to abnormal stimuli that underlie all diseases
General Pathology is our current understanding of the causation,
mechanisms and characteristic of the principal types of disease
process.

II. SYTEMETIC OR SYSTEMIC PATHOLOGY:

Systemic Pathology examines the specific responses of
specialized organs and tissues to more or less well defined
stimuli.
Systemic Pathology is the description of specific diseases as they
effect individual organs or organ systems (e.g. appendicitis, lung
cancer etc)
 FOUR ASPECTS OF A DISEASE PROCESS THAT
FORM THE CORE OF PATHOLOGY
The four aspects of a disease process that forms the core of
pathology are :
(i) Etiology or the cause of the disease

(ii) Pathogenesis or the mechanisms of disease

development

(iii) Morphologic Changes or the structural alterations

induced in the cells and organs of the body

(iv) Clinical Significance of the functional consequences

of morphologic changes in the form of symptoms
and signs of the disease.
 SKIN ABSCESS LUNG CANCER CIRRHOSIS HYPERTENSION

Characteristic of disease: The relationship between etiology, pathogenesis, morphological and

functional manifestations
 SCOPE OF PATHOLOGY

Pathology is the foundation of medical science and practice.

Without pathology the practice of medicine would be reduced to
myths and folklore.

Experimental Pathology : Scientific knowledge about human

diseases is obtained from experimental studies on animals
Clinical Pathology: Scientific knowledge is obtained about
human diseases from observations on patients.
 SUBDIVISIONS OF CLINICAL PATHOLOGY
Pathology is a vast subject with many ramifications. In
practice it has following major subdivisions:

 HISTOPATHOLOGY: The branch of pathology deals with the

the investigation and diagnosis of disease form the examination of
tissues

 CYTOPATHOLOGY: The investigation and diagnosis of disease

from the examination of isolated cells.

 HAEMATOLOGY: The branch of pathology which deals with

disorders of the cellular and coagulable components of blood.
 MICROBIOLOGY: The branch of pathology which deals with the
study of infectious diseases and the organisms responsible for
them
5. IMMUNOLOGY: The study of the specific defense mechanisms of
the body.
6. CHEMICAL PATHOLOGY: The study and diagnosis of disease
form the chemical changes in tissues and fluids.
7. GENETICS: The study of abnormal chromosomes and genes.
8. TOXICOLOGY: The study of effects of known or suspected
poisons.
9. FORENSIC PATHOLOGY: The application of pathology to legal
purposes (e.g. investigation of death in suspicious circumstances)
OVERVIEW OF CELLULAR
RESPONSES

TO

STRESS AND NOXIOUS

STIMULI
Cells are active participants in their
environment,constantly adjusting structure and
function to accommodate changing demands and
extracellular stresses

Cells tend to preserve their immediate

environment and intracellular milieu within a
relatively normal range of physiologic parameters
 CELL INJURY AND CELL DEATH
Stress on cell

Cell tends to preserve its intracellular milieu within a relatively

narrow range of physiologic parameters

Cell undergoes Adaptation (Hyperplasia, Hypertrophy, Metaplasia)

Adaptive capability fails: Cell Injury develops

Reversible Cell Injury

Severe & persistent stress: Irreversible Cell Injury

Ultimately Cell Death by two processes

NECROSIS APOPTOSIS
Relationship between normal, adapted,
Reversibly injured and dead myocardial
cells. The cellular adaptation depicted
here is hypertrophy , the type of
reversible injury is ischemic coagulative
necrosis
Stages in the cellular response to stress and injurious stimuli
Relationship between normal, adapted, reversibly injured and dead myocardial cells

Figure page 2 tobbins

The cellular adaptation depicted here is hypertrophy, the type of reversible injury is ischemia, and the irreversible
injury is ischemic coagulative necrosis . In the example of myocardial hypertrophy (lower left) , the left ventricular
wall is thicker than 2 cm (normal, 1- 1.5 cm). Reversibly injured myocardium shows functional effects without any gross
or light microscopic changes , or reversible changes like cellular swelling and fatty change . In the specimen showing
necrosis (lower left) the transmural light area in the posterolateral left ventricle represents and acute myocardial
infarction
 CELLULAR

ADAPTATIONS
Adaptations are reversible changes in the number , size,
phenotype, metabolic activity, or functions of cells in response
to changes in their environment.

PHYSIOLOGIC ADAPTATIONS: Usually represent responses

of cells to normal stimulation by hormones or endogenous
chemical mediators (e.g., hormone – induced enlargement
of the breast and uterus during pregnancy)

PATHOLOGIC ADAPTATIONS: Are responses to stress that

allow cells to modulate their structure and functions and thus
escape injury
 The cells of the body continue to grow, divide and differentiate
throughout life. Normally, growth and differentiation are
controlled in such a way as to maintain the normal structure of a
particular tissue.

 The growth of a tissue reflects the net balance of cell proliferation

on one hand and cell differentiation, leading to cell death on the
other hand.

 Cells can respond to excessive physiologic stresses or pathologic

stimuli by undergoing a number of physiologic and morphologic
Cellular Adaptations , in which a new but altered steady state is
achieved, preserving the viability of the cell and modulating its
function as a response to such stimuli.
Cellular Adaptations can proceed by a number of
mechanisms:

(i) Up or down regulation of specific cellular receptors

(ii) Induction of new protein synthesis by target cells.

(iii) Switch from producing one type of protein to

another.

(iv) Marked overproduction of a specific protein.

(v) By the virtue of the interplay of a variety of growth

factors with their corresponding receptors
 CELLUAR ADAPTATIONS:
Different Cellular adaptive responses are:

(i) Hyperplasia

(ii) Hypertrophy

(iii) Atrophy

(iv) Metaplasia
 ABNORMALITIES OF CELL GROWTH AND MATURATION
Abnormal Differentiation
Replacement of mature
cells of one type with
cells of another type
Regular organization of
of tissues maintained
Reversible
METAPLASIA
ATROPHY
Decrease in cell size & Number
Abnormal Differentiation
and maturation
 Partial loss of control
and organization
 Slight increase in cells
number
 Cytologic abnormalities
 Partially Reversible
DYSPLASIA
NORMAL CELL
HYPERTROPHY HYPERPLASIA
Increase in cell size
 Abnormal Differentiation
and maturation
 Marked increase in cell
number
 Complete loss of control
 Variable loss of organization
 Cytologic abnormalities
 Irreversible
NEOPLASIA
Increase in cell number
 HYPERTROPHY
Hypertrophy constitutes an increase in the size of cells and with such
change an increase in the size of organ . Thus, there are no new cells, just large
cells. Moreover, these cells are not enlarged by simple cellular edema but by the
increased synthesis of more structural proteins and organelles.
Hypertrophy can be Physiologic or Pathologic and is caused by
increased functional demand or due to specific hormonal stimulation.
Pure hypertrophy without accompanying hyperplasia occurs in muscle ,
and the stimulus is almost a mechanical one
a) Cardiac Muscle Hypertrophy: Any demand for increased work load on cardiac
muscle, i.e., in hypertension, valvular lesions or congenital heart diseases, leads
to hypertrophy of the fibers of the chamber affected.
b) Smooth Muscle Hypertrophy: Any obstruction to the outflow of the
contents of a hollow viscus results in hypertrophy of its muscle coat. The
following are examples of smooth muscle hypertrophy:
(i) Bladder: Seen in Prostatic enlargement and Urethral stricture
(ii) Oesophagus: Seen in carcinoma
(iii) Stomach: Seen in pyloric stenosis due to ulcer
or carcinoma
(iv) Intestine: Stricture following Tuberculous enteritis
(v) Colon: Seen in carcinoma and diverticular disease

c) Skeletal Muscle Hypertrophy:

The bulging muscle of the athlete/body
Builder provide a simple illustration of
hypertrophy due to a mechanical stimulus
 Cardiac Hypertrophy

Cardiac Hypertrophy involving left ventricle. The number of myocardial

fibres does not increase, but their size can increase in response to an
increased work load leading to the marked thickening of the left ventricle
in this patient with Systemic Hypertension
 Benign Prostatic Hyperplasia and Hypertrophy

The normal adult male prostate is about 3 to 4 cm in diameter. The

number of Prostatic glands, as well as stroma, has increased in this
enlarged prostate seen in cross section. The pattern of increase in
this case is uniform, but nodular
 Physiologic Hypertrophy of the Uterus during Pregnancy

Figure Robbins page 3

A: Gross appearance of a normal uterus (right) and a gravid uterus (left) that was
removed for postpartum bleeding
B: Small spindle – shaped uterine smooth muscle cells from a normal uterus
C: Large , plump hypertrophied smooth muscle cells from a gravid uterus
 Hypertrophy And Hyperplasia -Compared
Both are cellular responses to an increased demand for work.
The cells either enlarge or divide depending upon their growth
potentialities. The stimulus for this is usually mechanical in
hypertrophy, and chemical or hormonal in hyperplasia. When the
stimulus is withdrawn, the condition regresses and the tissue reverts
to normal . However, secondary structural alterations in the general
architecture due to an accompanying degeneration may render a
complete return to normal impossible.

Hypertrophy Hyperplasia

Stimulus is
Stimulus in Chemical and
Mechanical Hormonal
Hypertrophy And Hyperplasia -Compared
 HYPERPLASIA
Hyperplasia constitutes an increase in the number of cells in
an organ or tissue, that also leads to an increase in size of an
organ and tissue

Hypertrophy and Hyperplasia are closely related and often

develop concurrently in tissues, so that both may contribute to an
overall increase in organ size.
It is important to note that those hyperplasia due to a
specific stimulus persist only for so long as that stimulus is
applied. When it is removed, the tissue tends to revert to its
normal size. In this respect hyperplasia differs from neoplasia,
for neoplastic tissue continues to grow even when the stimulus is
withdrawn.
 Hyperplasia can be Physiologic or Pathologic:

(I) PHYSIOLOGIC HYPERPLASIA

a) Hormonal Hyperplasia: Exemplified by the proliferation of

glandular epithelium of the female breast at puberty and during
pregnancy

b) Compensatory Hyperplasia: Occurs when a portion of tissue

is removed or diseased. For example, when a portion of liver is
removed, hyperplasia by mitotic activity in the remaining cells
begins as early as 12 hours later, eventually restoring restoring
the liver to its normal weight – at which time cell proliferation
ceases. The stimuli for hyperplasia in this setting are
polypeptide growth factors. After restoration of the liver mass,
cell proliferation is “turned Off” by growth inhibitors
 PATHOLOGIC HYPEPRLASIA
Pathologic Hyperplasia and Hypertrophy occur in the absence of an
appropriate stimulus of increased functional demand
(i) Endometrial Hyperplasia: After a normal menstrual period there is
a burst of essentially physiologic hyperplasia. This proliferation is
normally tightly regulated between stimulation by pituitary
hormones and ovarian Estrogen, and inhibition by Progesterone.
However, if the balance between estrogen and progesterone is
disturbed (e.g., if there is absolute or relative increases in estrogen),
Pathologic Hyperplasia results. Endometrial Hyperplasia is a
common cause of abnormal menstrual bleeding. It is important to
note that the hyperplasic process remains controlled. If Estrogenic
stimulation abates, the hyperplasia disappears. This differentiates
the process from cancer, in which cells continue to grow despite the
absence of hormonal stimulus.
Nevertheless, pathologic hyperplasia constitutes a fertile soil in
which cancerous proliferation may eventually arise. Thus patients
with hyperplasia of the endometrium are at increased risk of
developing endometrial cancer
(ii)Compensatory hyperplasia of bone marrow: Following
haemorrhage
(iii) Reactive hyperplasia of lymphoid tissue in response to antigenic
stimulation.
(iv) Thyroid Hyperplasia (Graves’ Disease): Result from the action of
auto antibodies which act on follicular cells of thyroid and then
lead to hyperplasia of follicular cells, which in turn leads to
increased release of T3 and T4
(v) Hyperplasia of the Prostate Gland: It is common in older age and
is due to hyperplasia of both glandular and the stromal element
 Benign Prostatic Hyperplasia

Many glands with some intervening stroma. In the lumens of the

glands Corpora Amylacea is visible. The cells making up the glands
are normal in appearance, but they are increased in number.
HYPREPLASIA NEOPLASIA

Excited by a stimulus A stimulus is not always detected

Reversible, i.e., pathological Irreversible. i.e., cell proliferation

hyperplasia stops and disappears is unlimited and progresses
if stimulus is removed independent of stimuli
Proliferated cells are normal Proliferated cells are abnormal in
shaped shape

May be useful , i.e., Harmful

compensatory hyperplasia
 ATROPHY
Atrophy is the decrease in size of cell or of an
organ by loss of cell substance

Atrophy represents a reduction in the structural components of the cell.

In the changing circumstances the cells adopt themselves to survive with

lesser amounts of cellular substance, hence a new equiblrium is
achieved.

Although atrophic cells may have diminished function, they are not
dead.

If the blood supply is inadequate even to maintain the life of shrunken

cells then atrophy may progress to the point at which cells are injured
and die. The atrophic tissue is then replaced by fatty in growth.
 (I) PHYSIOLOGIC ATROPHY:

Physiologic Atrophy occurs at times from very early

embryonic life, as part of the process of morphogenesis. The process
of atrophy contributes to the physiological involution of different
organs
Some examples of Physiologic Atrophy are:

(i) Physiologic involution of Thymus.

(ii) post menopausal atrophy of Uterus
and Endometrium
(iii) Senile atrophy of cerebrum
(iv) Bone marrow atrophy in old age
 (II)PATHOLOGIC ATROPHY
Pathologic atrophy depends on the basic cause and can
be local or generalized. The common causes of atrophy are:

(i) Decreased workload (Atrophy of Disuse):

a) Skeletal muscle atrophy , when a broken limb is immobilized
in a plaster cast.
b) Skeletal muscle atrophy when a patient is restricted to
complete bed rest.

(ii) Loss of innervation (Denervation Atrophy): Damage to the nerves

leads to the rapid atrophy of the muscle fibers supplied by those nerves,
for example in poliomyelitis and in paraplegics.

(iii) Diminished Blood Supply (Ischemia): In late adult life, the brain
undergoes progressive atrophy , presumably as atherosclerosis narrows
its blood supply.
(iv) Inadequate Nutrition:
a) Profound protein – calorie malnutrition (marasmus) is
associated with marked muscle wasting.
b) In starvation.
c) Cachexia: An extreme form of systemic atrophy, usually
seen in cancer patients

(v) Loss of Endocrine Stimulation:

Many endocrine glands, the breast, and the reproductive
organs are dependent on endocrine stimulation for normal function. Loss
of estrogen stimulation after the menopause results in physiologic
atrophy of the endometrium, vaginal epithelium and breast.

(vi) Aging (Senile Atrophy): The aging process is associated with cell loss.
Morphologically, it is seen in tissues containing permanent cells,
particularly in the brain and heart.
(vii) Pressure: Tissue compression for any length of time can cause
atrophy. An enlarging benign tumour can cause atrophy in the
surrounding compressed tissues. Atrophy in this setting is probably
the result of ischemic changes caused by a blockade of blood supply
produced by the expanding mass
 Testicular Atrophy

Atrophy testis : Right testis undergo atrophy and is much smaller

than the normal testis at the left
 Atrophy Brain

Cerebral atrophy in a patient with Alzheimer disease. The gyri are

narrowed and the intervening sulci widened particularly pronounced
towards the frontal lobe
A. Physiologic atrophy of the brain in an 82 years old man
B. Normal brain of a 36 years old male
 METAPLASIA
Metaplasia is a reversible change in which one adult
cell type (epithelial or mesenchymal) is replaced by another
cell type.

Metaplasia often represents an adaptive response of a

tissue to some stress, and is presumed to be due to the activation and/or
repression in tissue stem cells of group of genes involved in tissue
differentiation. The transdifferentiated cells replace the original cells.
Metaplasia is of two types
1. Epithelial Metaplasia
- Columnar to Squamous
- Squamous to Columnar
2. Connective Tissue Metaplasia
Stress Stimuli

Elaboration of Growth Factors, Cytokines, etc

Pluripotent Mesenchymal Stem Cell

Reprogramming of Stem Cell

Metaplasia

Can lead to Dysplasia, if stress or stimulus persists

Dysplasia can then lead to Carcinoma

 EPITHELIAL METAPLASIA
(i)Squamous metaplasia:
The most common epithelial metaplasia is Columnar to
Squamous . In different conditions under conditions of stress, the
fragile columnar epithelium is replaced by more rugged stratified
epithelium, which can withstand the adverse environment. Common
examples of squamous metaplasia are :
a) In respiratory tract of cigarette smokers the normal columnar
ciliated epithelial cells of trachea and bronchi are often replaced by
stratified squamous epithelial cells.
b) Stones in the excretory ducts of the salivary glands, pancreas or
bile ducts may cause replacement of the normal secretary columnar
epithelium by non functioning stratified squamous epithelium
c)Transitional bladder epithelium in the presence of stones, and in
the presence of ova of the trematode Schistosoma Haematobium get
transformed into squamous epithelium.
Schematic Diagram of Columnar to Squamous Metaplasia
 Metaplasia of Respiratory Epithelium

Metaplasia of laryngeal respiratory epithelium has occurred here in a

smoker . The chronic irritation has led to an exchange of one type of
epithelium (the normal respiratory epithelium at the right ) for another
( more resilient squamous epithelium at the left). Metaplasia is not a
normal physiologic process and may be a first step toward neoplasia
(ii)Columnar Metaplasia:
Metaplasia from squamous to columnar type may also occur:
a)Barrett Esophagitis: In this condiiton the
squamous esophageal epithelium is replaced
by intestinal-like columnar cells. The resulting
cancers that may arise are glandular (adeno)
carcinomas.
b) Cervical Erosion: Squamous epithelium of cervix
is replaced by columnar epithelium.

Metaplastic transformation
Of esophageal stratified
squamous epithelium
to mature columnar
epithelium (so-called
Barrett metaplasia)
Metaplasia of the normal esophageal squamous mucosa has occurred,
with the appearance of gastric type columnar epithelium
 In all these instances the more rugged stratified squamous
epithelium is able to survive under the circumstances in which the
more fragile specialized epithelium most likely would have
succumbed, so the metaplastic tissue is better able to withstand the
adverse environmental changes.

Epithelial Metaplasia is a two –edged sword and, in most

circumstances, represents an undesirable change. Moreover, the
influences that predispose to such metaplasia, if persistent, may
induce cancer transformation in metplastic epithelium.
 CONNECTIVE TISSUE METAPLASIA

Connective tissue metaplasia is the formation of cartilage,

bone or adipose tissue (mesenchymal tissues) in tissues that
normally do not contain these elements. For example, bone formation
in muscle, designated Myositis Ossificans , occasionally occur
after bone fracture.
This type of metaplasia is less clearly seen as an adaptive
response.
 Hyperplasia Versus Metaplasia

Hyperplasia Metaplasia
Definition

It is an increase in the number of cells in an organ or It is a reversible change in which one type of cell is
tissue usually resulting in an increase in volume of differentiated into another type of differentiated
the organ or tissue epithelium
Cause

Physiological or Pathological Pathological

Mechanism

Increased production of growth factors, growth Result of reprogramming of stem cells; Precursor
factor receptors, activation of signaling pathways, cells differentiate along a new pathway; Tissue
production of transcription factors leading to specific and differentiation genes are involved in
cellular proliferation process
Examples

Physiological: Uterus, breast growth during
pregnancy; Compensatory hyperplasia in unilateral
nephrectomy and partial hepatectomy
Pathological: Parathyroid hyperplasia occurring in
chronic renal failure; thyroid hyperplasia in graves
disease; Benign prostatic hyperplasia ;endometrial
hyperplasia
Squa mous metaplasia : gall bladder, renal pelvis
and bladder, uterus/cervix, bronchial, prostatic
Columnar Metaplasia: Barret’s esophagus, cervical
erosion, chronic bronchitis, bronchiactasis,
fibrocystic disease with apocrine metaplasia
Osseous metaplasia: Aging process in costal and
thyroid cartilage, in scars, areas of dystrophic
calcification , myositis ossificans
 DYSPLASIA
Dysplasia is a premalignant condition characterized by the
loss of the uniformity of the individual cells as well as a loss in their
architectural orientation.

Dysplasia can be caused by longstanding irritation of a

tissue, with chronic inflammation, or by exposure to carcinogenic
substances.

Dysplasia may occur in tissues which has coincident

metaplasia, e.g. dysplasia developing in metaplastic squamous epithelium
from the bronchus of smokers

Dysplasia may also develop without co-existing

metaplasia , for example in squamous epithelium of the uterine cervix,
glandular epithelium of the stomach or the liver

Dysplasia may be present for many years before a

malignant neoplasm develops, and this observation can be used to screen
populations at high risk of developing tumours
Dysplatic cells exhibit following characteristic findings:
I) Cellular Pleomorphism: Cells show variations in size & shape
ii)Hyperchromatic Nuclei: Deeply stained nuclei, which are
abnormally large for the size of cell.
iii)Increased Mitotic Activity: Mitotic figures are more
abundant than usual, although almost invariably they conform
to normal patterns. In dysplasia the mitoses are not confined
to the basal layers and may appear at all levels and even in
surface cells.
(iv) Architectural Anarchy : There is considerable architectural
anarchy. For example, the usual progressive maturation of tall
cells in the basal layer to flattened squames on the surface
may be lost and replaced by a disordered scrambling of dark
basal- appearing cells. This is also labeled as ‘loss of
epithelial polarity’
(v)Carcinoma in situ: When dysplastic changes are marked and
involve the entire thickeness of the epithelium, but the
basement membrane is intact the lesion is considered as
preinvasive neoplasm and is referred as carcinoma in situ.
 Normal Dysplasia

Invasion

Carcinoma in situ

Metastasis
 DYSPLASIA CERVIX

The normal cervical squamous epithelial at left transform to dysplastic

change at right. There is also underlying chronic inflammation because
abnormal epithelial surfaces do not provide the same protective barrier
as normal epithelial surfaces do
 PAP SMEAR CERVIX

PAP SMEAR: Cytologic features of normal squamous epithelial cells can be

seen at the center top bottom, with orange to pale blue plate- like squamous
cells that have small pyknotic nuclei . The dysplastic cells in the center
extending to upper right are smaller with darker, more irregular nuclei
Overview of
Cell Injury
&
Cell Death
Cell injury results when cells are stressed so severely that
They are no longer able to adopt or when cells are exposed
to inherently damaging agents or suffer from intrinsic
Abnormalities
Reversible Cell Injury
In early stages or mild forms of injury the functional and
morphological changes are reversible if the damaging
stimulus is removed.
At this stage ,although there may be significant structural
and functional abnormalities, the injury has typically not
progressed to severe membrane damage and nuclear
dissolution
Cell Death
With continuing damage the injury becomes irreversible,
at which time the cell cannot recover.
There are two types of cell death:
(i) Necrosis
(ii) Apoptosis
 CELL INJURY AND CELL DEATH
Stress on cell

Cell tends to preserve its intracellular milieu within a relatively

narrow range of physiologic parameters

Cell undergoes Adaptation (Hyperplasia, Hypertrophy, Metaplasia)

Adaptive capability fails: Cell Injury develops

Reversible Cell Injury

Severe & persistent stress: Irreversible Cell Injury

Ultimately Cell Death by two processes

NECROSIS APOPTOSIS
Causes
of
Cell
Injury
 Causes of Cell Injury
Causes of cell injury range from the gross

physical trauma of a motor vehicle accident to

the single gene defect that results in a defective

enzyme underlying a specific metabolic disease

 CAUSES OF CELL INJURY
1. Oxygen Deprivation (Hypoxia)
(i) Ischemia: Loss of blood supply to a tissue
(ii) Anaemia: Decreased haemoglobin, which in turns leads to
decreased oxygenation

2. Physical Agents
(I )Mechanical trauma.
(ii) Extremes of temperature (burns and deep cold)
(iii) Radiation and Electric shock

3. Chemical Agents and Drugs

(i) Poisons such as Arsenic and Cyanide
(ii) Glucose or salts in hypertonic concentrations
(iii) Environmental or Air Pollutants
(iv) Alcohol and Narcotic Drugs
(v) Insecticides and herbicides
4. Infectious Agents
Like Viruses, Bacteria, Fungi, Parasites
5. Immunologic Reactions: Immune system serves as defense against
biologic agents; Immune reactions may in fact, cause cell injury ,
for example:
(i) Autoimmune Diseases
(ii) Anaphylactic Reactions

6. Genetic Derangements: Genetic defects may result in pathologic

changes as conspicuous and obvious as the congenital
malformations associated with down syndrome or a subtle as the
single amino acid substitution in haemoglobin S of Sickle Cell
Anaemia
7. Nutritional Imbalances
(i) Protein Calorie Deficiencies
(ii) Vitamin Deficiency
(iii) Lipids excess predispose to Atherosclerosis
8. Aging
Cellular senescence leads to alterations in replication
and repair abilities of individual cells and tissues.
All of these changes result in a diminished ability to respond to damage
and, eventually , the death of cells and of the organism
Morphology
of
Cell
and
Tissue Injury
All stresses and noxious influences exert their effects first
at the molecular or biochemical levels.

Cellular functions may be lost long before cell death occurs,

and the morphologic changes of cell injury (or death) lag
behind both .

The cellular derangements of reversible injury can be

repaired and, if the injurious stimulus abates , the cell
will return to normalcy.

Persistent or excessive injury , however , causes cell to pass

into the stage of irreversible cell injury and cell death.
Schematic diagram demonstrating the relationship between cellular function,
cell death, and the morphologic changes of cell injury. Note that cells may
become rapidly nonfunctional after the onset of injury , although they are
still viable with potentially reversible changes; a longer duration of injury
may eventually lead to irreversible injury and cell death
 Point of No Return
Two phenomena consistently characterize irreversibility :

(1)The inability to reverse mitochondrial dysfunction

(lack of oxidative phosphorylation and ATP generation)
even after resolution of original injury

(2) Profound disturbances in membrane function

 Reversible Cell Injury: Morphologic Changes

The two main morphologic correlates of reversible

cell injury are:
(i) Cellular Swelling: It is the result of failure of energy
dependent ion pumps in the plasma membrane, leading
to an inability to maintain ionic and fluid homeostasis.

(ii) Fatty Change: It occurs in hypoxic injury and various

forms of toxic or metabolic injury. It is manifested by the
appearance of small or large lipid vacuoles in the cytoplasm.
It occurs mainly in cells involved in and dependent on
fat metabolism, such as hepatocytes and myocardial cells
Reversible Cell Injury: Morphologic Changes….. contd
(i) Cellular Swelling
It is the first manifestation of almost all forms of injury to cells.
It is difficult to appreciate with light microscope; it may be more
apparent at the level of whole organ.
Gross Examination: When it effects many cells in an organ,
it causes some pallor, increased turgor, and increase
in weight of the organ.
Microscopic Examination: May reveal small, clear vacuoles ,
within the cytoplasm ; these represent distended and pinched
off segments of the endoplasmic reticulum .
This pattern of non- lethal injury is sometimes called hydropic
change or vacuolar degeneration.
 (ii) Fatty Change
It is manifested by the appearance of lipid vacuoles in the
cytoplasm . Injured cells may also show increased
eosinophilic staining . This eosinophilic staining becomes
more pronounced with progression to necrosis
 Ultra structural changes of Reversible Cell Injury

(1)Blebbing of plasma membrane

(2)Blunting or distortion of microvilli
(3)Loosening of intercellular attachments
(4)Swelling and appearance of phospholipid – rich
amorphous densities in mitochondria
(5) Dilation of endoplasmic reticulum
(6) Detachment of ribosomes
(7) Nuclear alterations with clumping of chromatin
 Morphologic changes in reversible and irreversible
cell injury (necrosis)

Normal kidney tubules with viable epithelial cells

 Morphologic changes in reversible and irreversible
cell injury (necrosis)

Early (reversible) ischemic injury showing surface blebs,

Increased eosinophilia of cytoplasm ,and swelling of
occasional cells.
 Morphologic changes in reversible and irreversible
cell injury (necrosis)

Necrotic (irreversible) cell injury of epithelial cells with loss of nuclei

and fragmentation of cells and leakage of contents
A normal cell and changes in
reversible and irreversible
cell injury (Necrosis)
NORMAL CELL
REVERSIBLE CELL INJURY
IRREVERSIBLE CELL INJURY
 NECROSIS
“Sum of the morphologic changes that follow
cell death in a living tissue or organism’’.
Two mechanisms are involved in necrosis:
1. Enzymatic digestion of cells by catalytic
enzymes
(i) Autolysis: Catalytic enzymes derived from
the lysosomes of dead cells.
(ii) Heterolysis: Catalytic enzyme derived from
lysosomes of immigrant leucocytes.

2. Denaturation of Proteins
 TYPES OF NECROSIS

Several distinct types of necrosis are

recognized:

1. Coagulative Necrosis

2. Liquefactive Necrosis

3. Caseous Necrosis

4. Gangrenous Necrosis

5. Fibrinoid Necrosis

6. Fat Necrosis
 Morphologic Changes in Necrosis
A. Changes in Cytoplasm
Increased Eosinophilia: It is due to:
a) Loss of normal basophilia imparted by RNA in the
cytoplasm
b) Increased binding of Eosin to denatured
intracytoplasmic proteins
Cell will assume a glassy homogenous appearance . It is
due to loss of glycogen particles
Due to digestion of cytoplasmic organelles by enzymes, the
cytoplasm will appear vacuolated and appear moth- eaten
Calcification of dead cell may occur
B. Changes in Nucleus
Pyknosis: Shrinkage of nucleus
Karyolysis: Dissolution of nucleus
Karyorrhexis: Fragmentation of nucleus
 Dead Necrosed cell
At the end nucleus will be lost
and dead cell will appear as
anucleated eosinophilic body

 Typical appearance of necrosed

tissue will be eosinophilic
grnaular
 I.CAOGULATIVE NECROSIS
Coagulative Necrosis is the most common type of necrosis.
The process of coagulative necrosis, with preservation of the
general tissue architecture is characteristic of hypoxic death of
cells ( due to lack of blood supply) in all tissues except brain
The pathogenesis of coagulative necrosis is denaturation
of proteins.
Myocardial Infarction is an important example of
coagulative necrosis. It is also seen in infarcts of heart, kidney
and spleen.

Part of kidney deprived of its blood

supply by an arterial embolus. This
is an example of caogulative necrosis
Cellular and nuclear detail has been
Lost. The ghost outline of a glomerulus
can be seen in the centre, with
remnants of tubule elsewhere
 Fig A Fig B

Fig A: Normal Myocardium

Fig B: Myocardium with coagulation necrosis (upper two thirds of figure),
showing strongly eosinophilic anucleate myocardial fibers.
Leucocytes in the interstetium are an early reaction to necrotic
muscle .
Compare with A and with normal fibers in the lower part of figure
COAGULATIVE NECROSIS – MYOCARDIAL INFARCTION

When there is marked cell injury, there is cell death. This microscopic
appearance of myocardium is a mess because so many cells have
died that the tissue is not recognizable. Many nuclei have become
Pyknotic (shrunken and dark) and have then undergone Karorrhexis
(fragmentation) and Karyoloysis (dissolution) . The cytoplasm and
cell borders are not recognizable
 II. LIQUEFACTIVE NECROSIS
 Liquefactive necrosis is the type of necrosis in which
necrosed tissue is completely liquified
 Liquefactive Necrosis is characteristically seen in:
(i) Hypoxic death of cells within the central nervous
system
(ii) Bacterial or occasionally fungal infections.
Liquefaction completely digests the dead cells. The end
result is transformation of the tissue into a liquid viscous
mass. If the process had been initiated by acute
inflammation, the material is frequently creamy yellow
because of the presence of dead white cells and is called
pus.

A focus of liquefactive necrosis in the

kidney caused by fungal seeding. The
focus is filled with white cells and
cellular debris, crating a renal abscess
that obliterates the normal architecture
 LIQUEFACTIVE NECROSIS BRAIN

Grossly , the cerebral infarction at the upper left here demonstrates

liquefactive necrosis. Eventually, the removal of dead tissue leaves
behind a cavity.
 Normal Cell

Lethal Cytoplasm organelles lost,

Injury Cytoplasm appears
Eosinophilic and uniform
Nuclear
Pyknosis

Karyorrhexis
End Result: Cell retaining
membrane and coagulated
cytoplasm with absent nucleus

Cells have undergone Cells retain outline

lysis, so that necrotic necrotic area is
area is converted to solid composed of
fluid- filled cyst ghost cells

LIQUEFACTIVE COAGULATIVE
NECROSIS NECROSIS
 III. CASEOUS NECROSIS
A distinctive form of coagulative
necrosis . It is encountered most often in foci of
Tuberculosis Infection.The term caseous is derived
from gross appearance of tissue (white and cheesy)
Microscopic Appearance: The necrotic focus
appears as amorphous granular debris composed of
fragmented, coagulated cells and amorphous
granular debris enclosed within a distinctive
inflammatory border known a
“ Granulomatous Reaction”
 Gross Appearance of Caseous necrosis: Foci of caseous necrosis in
Tuberculosis of Lung

Microscopic Appearance of Caseation Necrosis: Characteristic Tubercle

showing central necrosis, along with epithelioid cells, multinucleated
Giant cells and lymphocytes
EXTENSIVE CASEOUS NECROSIS LUNG IN TUBERCULOSIS

Extensive caseous necrosis lung in Tuberculosis, with confluent cheesy

granulomas in the upper portion.
 IV. GANGRENOUS NECROSIS
 Gangrene is massive necrosis (Caused by acute ischemia or severe
bacterial infection) followed by putrefaction
Gangrene is a special type of necrosis, in which bacterial infection is
superimposed on coagulative necrosis and coagulative necrosis is
modified by the liquefactive action of the bacteria
The bacteria proliferate in and digest the dead tissue often with the
production of foul smelling gases. The tissue becomes green or black
because of the production of iron sulphide from degraded
haemoglobin (PUTREFACTION)
There are two main types of gangrene: (i) primary ; (ii)
Secondary
(I) Primary (Gas Gangrene): It is due to infection
of deep contaminated wounds in which there is
considerable muscle damage, by bacteria of the
CLOSTRIDIA group- anaerobic spore forming gram
positive bacilli which produce saccharolytic and
proteolytic enzymes resulting in digestion of muscle
tissue with gas formation. The infection rapidly
spreads and there is associated severe toxaemia
(spread of poisons in the blood)
(ii) Secondary Gangrene: This is due to invasion of necrotic tissue
usually by a mixed bacterial flora including putrefactive organisms
and occurs in two forms:
a) Wet gangrene: It occurs due to Arterial and venous occlusion. The
tissues are moist at the start of the process either due to oedema or
venous congestion. Examples are in strangulation of viscera and
occlusion of leg arteries in obese diabetic patients

b) Dry Gangrene: It occurs due to

Arterial occlusion. Occurs especially in the toes
and feet of elderly suffering from gradual
arterial occlusions; the putrefactive process
is very slow and only small numbers of
putrefactive organisms are present.
In Dry gangrene distal to arterial occlusion, tissue fluid formation will
stop, but since veins are patent, the already present tissue fluid will be
drained into the veins as normal
DRY GANGRENE WET GANGRENE

Due to Arterial occlusion Due to Arterial and Venous occlusion

Occurs n limbs in cases of Occurs in limbs in

- Senile gangrene - Crush injuries
- Berger's gangrene - Tight tourniquets
- Raynaud’s disease - Bed sores
- Sometimes in diabetic gangrene - Diabetic gangrene
Does not occurs in internal organs Occurs in internal organs (intestine)

Very slow Putrefaction Rapid Putrefaction decomposition of dead

tissue by bacteria leading to formation of
iron sulphide, which in turns impart
greenish – black colour to tissue)

Mild Toxemia Severe Toxemia

Gangrenous part is dry and mummified Gangrenous part is swollen

Prominent line of demarcation(Dead Poor line of demarcation

gangrenous part separates from the
living part very distinctively)
 DRY GANGRENE TOES

This is Gangrene, or necrosis of toes. The toes were involved in

a frost bite injury. This is an example of ‘dry gangrene’ in which
there is mainly coagulative necrosis due to anoxic injury
 WET GANGRENE LEG

This is Gangrene of the lower extremity . In this case the term ‘wet
gangrene’ is more applicable because of the liquefactive component
from superimposed infection in addition to the coagulative
necrosis from loss of blood supply. This patient had Diabetes
Mellitus.
Gangrenous inflammation
 V: FAT NECROSIS

Fat Necrosis may be due to:

(i) Direct Trauma to adipose tissue and extracellular

liberation of fat. The result may be a palpable mass,
particularly at a superficial site such as the breast

(ii) Enzymatic lysis of fat due to release of

Lipases. In Acute Pancreatitis there is release of
pancreatic lipase. As a result, fat cells have their stored fat
split into fatty acids, which then combine with calcium to
precipitate out as white soaps.
 FAT NECROSIS PANCREAS

Cellular injury to the pancreatic acini leads to release of powerful

enzymes which damage fat by the production of soaps (combination
of calcium salts with fat’ ;fat saponification)), and these appear
grossly as the soft Chalky white areas seen in this cut
surface
Fat Necrosis in acute pancreatitis: The areas of chalky white deposits
represents foci of fat necrosis with calcium soap formation
(Saponification) at sites of lipid breakdown in the mesentery
 VI. FIBRINOID NECROSIS
Fibrinoid Necrosis is a type of Connective Tissue Necrosis It
is seen particularly in conditions where there is Deposition of
Antigen – Antibody Complexes . The important examples
are Autoimmune Disorders like Systemic Lupus Erythematosus ,
Rheumatic Fever and Polyartirtis Nodosa. In these conditions the
media and smooth muscle of blood vessels are especially involved
Fibrinoid Necrosis is characterized by loss of normal
structure and replacement by a
homogenous, bright pink-staining
necrotic material that resembles
fibrin microscopically.
Note, however, that “fibrinoid” is not
The same as occurs in inflammation
and blood coagulation. Areas of
fibrinoid necrosis contains various
amounts of Immunoglobulins,
complement, albumin, break down
products of collagen and fibrin
Fibrinioid Necrosis in an artery in a patient with polyarteritis nodosa.
The wall of the artery shows a circumferential bright pink area of necrosis
with protein deposition and inflammation ( dark nuclei of neutrophils)
 Differences Between Different Types of Necrosis
CAGULATIVE LIQUEFACT- CASEOUS FAT FIBRINOID
NECROSIS IVE NECROSIS NECROSIS NECROSIS
NECROSIS
Occurs due to Occurs due to Occurs due to Occurs due to Due to
ischemia ischemia granuloma- trauma or vascular
tous disease enzymatic fat inflammation
injury

In various In Brain In any tissue In Pancreas Around Blood

tissues and Breast Vessels

Tissue Architecture Cheesy Architecture Architecture

architecture destroyed material; distorted not much
preserved Architecture affected
disturbed

Involves Denaturation Caseation Rupture of Fat Accumulation

denaturation of Proteins & cells of Fibrinoid
of protein & Autolysis material
lysosomal
enzymes
 Biochemical Markers of Necrosis

Enzymes Tissue

Creatinine Kinase(MB isoenzyme) Heart

Certainties Kinase(BB isoenzyme) Brain
Creatinine Kinase(MM isoenzyme) Skeletal Muscle
Lactic Dehydrogenase(Isoenzyme 1) Heart, Erythrocytes, Skeletal
Muscle
Lactic Dehydrogenase (Isoenzyme 5) Liver, Skeletal Muscle

Aspartate Aminotransferase(AST) Heart, Liver, Skeletal Muscle

(Glutamic Oxaloacetate Transferase
; SGOT)
Alanine Aminotransferase (ALT) Liver, Skeletal Muscle
(Glutamic Oxaloacetic Transferase ;
SGPT)
Amylase Pancreas, Salivary Gland
 SEQUALAE OF CELL DEATH
Eventually, in the living patient, most necrotic cells and
their debris disappear by a combined process of extracellular enzyme
digestion and leucocyte phagocytosis. If necrotic cells and cellular debris
are not promptly eliminated, they tend to attract calcium salts and other
minerals and become calcified
Cell Death

Necrosis

Further Autolysis Putrefaction Dystrophic

and Inflammation Calcification

Demolition Gangrene

Absorption

Repair Regeneration
 Necrosis: Summary
 Necrosis is death of tissues: causes include ischemia, metabolic,
trauma.
 Coagulative necrosis is seen in the most tissues; firm pale area, with
ghost outlines on microscopy.
 Liquefactive necrosis is seen in the brain; the dead area is liquefied.
 Caseous necrosis is seen in tuberculosis; there is pale yellow semi-
solid material
 Gangrene is necrosis with putrefaction: it follows vascular
occlusion or certain infections and is black .
 Fibrinoid necrosis is a microscopic feature in arterioles in where
there is antigen- antibody complexes accumulation.
 Fat necrosis may follow trauma (e.g., in breast) and cause a mass, or
may follow pancreatitis visible as multiple white spots
APOPTOSIS
 APOPTOSIS
“Programmed Cell Death”
 It is a form of cell death designed to eliminate unwanted host cells
through activation of coordinated, internally programmed series of
events effected by a dedicated set of gene products.

 Apoptosis occurs when a cell dies through activation of an

internally controlled suicide program.

 It is a subtly orchestrated disassembly of cellular components

designed to eliminate unwanted cells, during embryogenesis and in
various physiologic processes.

 Doomed cells are removed with minimum disruption to the

surrounding tissue.

 It also occurs, however, under pathologic conditions , in which it

is sometimes accompanied by necrosis
Control of tissue growth by induction or inhibition of
Apoptosis: Quiescent (mitotically inactive) cells in G0 are recruited into a high
turnover (mitotically active) state by growth factors. Their subsequent fate depends
on the presence or absence of apoptosis inducers or inhibitors.
Apoptosis inducers are mediated by bax protein
Apoptosis inhibitors are mediated by bcl – 2 protein
 Apoptosis refers to a mechanism of cell death affecting
usually single cells or a group of cells scattered in a population
of healthy cells. It differs from necrosis and represents most of
the times a physiological or at times a pathological response by
which effete cells and abnormal cells die and are eliminated.
The process is rapid and ( completed in few hours), and is
considered in 2 stages:
Stage 1 (Dying Process):
a) Active metabolic changes in the cell cause cytoplasmic and
nuclear condensation and nuclear membrane is intact.
b) Cell disintegrates into multiple Apoptotic Bodies , each
surrounded by a part of plasma membrane.

Stage 2 (Elimination Process): Phagocytosis of Apoptotic

Bodies by surrounding cells ,e.g., liver cells, tumour cells.
This is followed by rapid digestion. The surrounding cells move
together to fill the vacant space leaving virtually no evidence of
the process.
 PATHOGENESIS OF APOPTOSIS

Apoptosis results from the action of intacellular

cysteine protease called CASPASES which are activated
following cleavage and lead to endonuclease digestion of DNA and
disintegration of the cell skeleton.
There are two major pathways by which caspases are
activated:
(i) Activation through Death Factor (Fas Ligand): The is by signaling
through membrane proteins such as Fas or TNF receptor intracellular
death domain. An example of this mechanism is shown by activated
cytotoxic T cells expressing Fas ligand.
(ii) Release of Cytochrome – C from the Mitochondria: The second
pathway is via the release of Cytochrome – C from mitochondria .
Cytochrome – C binds to Apaf – 1 which then activates caspases.
DNA damage induced by irradiation or chemotherapy may act
through this pathway.
Representation of apoptosis. Apoptosis is initiated via two main stimuli (i) Signaling
through cell membrane receptors such as FAS tumor necrosis factor (TNF) receptor
or (ii) release of cytochrome c from mitochondria. Membrane receptors signal apoptosis
through an intracellular death domain leading to activation of caspases
which digest DNA. Cytochrome C binds to the cytoplasmic protein Apaf -1 leading to
activation of caspases.The intracellular ratio of pro(e.g. BAX) or anti-apoptotic
(e.g. BCL) factors may influence mitochondrial Cytochrome- C release. Growth factors raise
the level of BCL -2 inhibiting Cytochrome - C release whereas DNA damage, by activating
p53 , raises the level of BAX which enhances cytochrome c release
 Balance Between Pro- Apoptotic and Anti –
Apoptotic Proteins Expression and their effects on
Cytochrome C

1. Proapoptotic Protein : BAX Protein : The protein p53 has an

important role in the sensing DNA damage. It activates apoptosis by
raising the cell level of BAX which then increases Cytochrome – C
release. It also shuts down the cell cycle to stop the damaged cell
from dividing . Following death, apoptotic cells display molecules
that lead to their ingestion by macrophages.
DNA damage, by activating p53, raises the level of
BAX which enhances Cytochrome – C release

2. Anti- Apoptotic Protein: BCL – 2; As well as molecules that

mediate apoptosis there are several intracellular proteins that protect
cells from apoptosis. The best characterized example is BCL – 2.
Growth factors raise the level of BCL -2 thereby inhibiting
Cytochrome – C release.
 Postulated sequence of events in Apoptosis
Extrinsic Triggers Intrinsic Triggers
*Withdrawal of growth Intrinsic Protease activation
factors or hormones
*Receptor – ligand interactions
FAS / FAS ligand
TNF / TNF receptor
*Injury (radiation; toxins; free radicals)
* Cytotoxic T cells

Intrinsic Protease ( Caspases) activation

Endonuclease mediated Breakdown of Cytoskeleto

fragmentation of nuclear chromatin

Formation of Apoptotic bodies containing various intracellular organelles

Expression of “Phosphatidylserine” & “Thrombospondin” on Apoptotic bodies

Recognition by macrophages and phagocytosis without proinflammatory

cellular components
 Mechanisms of Apoptosis

1. Mitochondrial (Intrinsic) pathway of Apoptosis :Mitochondria

contain several proteins that are capable of inducing
apoptosis; these proteins include Cytochrome-c and
other proteins that neutralize endogenous inhibitors of
apoptosis
2. Death receptor (Extrinsic) pathway of Apoptosis: Many
cells express surface molecules called death receptors ,
that trigger apoptosis.
3. Activation of Caspases : Mitochondrial and death
receptor pathways lead to the activation of Initiator
Caspases .Active forms of these enzymes are produced,
and these cleave and thereby activate another series of
caspases that are called Executioner Caspases
4. Clearance of Apoptotic Cells: Apoptotic cells entice
phagocytes by producing “eat me” signals .In normal
cells phosphotidylserine is present on the inner leaflet
of the plasma membranes, but in apoptotic cells this
phospholipid “flips” to the outerleaflet ,where it is
srecognized bt macrophages
Mechanisms of Apoptosis: the two pathways of apoptosis differ in their
induction and regulation, and both culminate in the activation of caspases.
In the mitochondrial pathway, proteins of Bcl-2 family, which regulate
mitochondrial permeability become imbalanced and leakage of various
substances from mitochondria leads to caspase activation.
In the death receptor pathway , signals form plasma membrane
receptors lead to assembly of adaptor protiens into a “death – inducing
signaling complex” ,which activates caspases and the end result is
the same
 Examples of Apoptosis

1. Growth Factor Deprivation :Hormone sensitive cells

deprived of the relevant hormon,lymphocytes that are
not stimualted by antigens and cytokines and
neurpons deprived of nerve growth factor die by
apoptosis
2. DNA Damage: Exposure of cells to radiation or
chemotherapeutic agents induces DNA damage ,which
if severe may trigger apoptotic death.
3. Accumulation of Misoflded Proteins: ER Stress: During
normal protein synthesis, chaprones in the ER control
proper folding of newly synthesized proteins and
misfolded polypeptidies are ubiquitinated and targeted
for proteolysis. Various external stresses or mutations
induce a state called Endoplasmic Reticulum Stress ,
in which the cell is unable to cope wit hthe load of
misfolded proteins. Accumulation of these proteins in
the ER triggers the unfolded response, which tires to
restore protien homeostasis; if this respons eis
inadequate, the cell dies by apoptosis
The unfolded protein response and ER stress:
A: In healthy cells, newly synthesized proteins are folded with the help of
chaperones and are incorporated into cell or secreted
B. Various external stresses or mutations induce a state called
Endoplasmic Reticulum Stress , in which the cell is unable to cope wit
hthe load of misfolded proteins. Accumulation of these proteins in the ER
triggers the unfolded response, which tires to restore protein
homeostasis; if this respons eis inadequate, the cell dies by apoptosis
 APOPTOSIS SPECIFIC GENE
Gene that stimulates Apoptosis
e.g., bax – gene

APOPTOSIS INHIBITING GENE

Gene that blocks apoptosis
e.g., bcl - gene
 PHYSIOLOGIC CONDIITONS
HAVING EVIDENT APOPTOSIS
1.The programmed destruction of cells during embryogenesis.

2. Hormone dependent involution in the adults, such as endometrial

breakdown during menstrual cycle and regression of lactating breast
after weaning

3. Cell depletion in proliferating cell population, such as intestinal crypt

epithelia, in order to maintain a constant number

4. Elimination of cells that have served their useful purpose, such as

neutrophils in an acute inflammatory response and lymphocytes at the
end of an immune situations
5. Elimination of potentially harmful self-reactive lymphocytes either before
or after they have completed their maturation , in order to prevent
reactions against the body’s owns tissues
6. Cell death induced by cytotoxic T lymphocytes , a defense mechanism
against viruses and tumours that serves to kill virus-infected and
neoplastic cells
 PATHOLOGIC CONDIITONS
HAVING EVIDENT APOPTOSIS
1.DNA damage: Radiation, cytotoxic anticancer drugs, extremes of
temperatures and even hypoxia can damage DNA, either directly or
through production of free radicals.

2. Accumulation of misfolded proteins :Improper folded proteins may arise

because of mutations in the genes encoding these proteins or because
of extrinsic factors , such as damage caused by free radicals. Excessive
accumulation of these proteins in the ER leads to a condition called
Endoplasmic Reticulum Stress (ER Stress) ,which culminates in a
apoptotic death of cells
3. Cell injury in certain infections, particularly viral infections, in which
loss of infected cells is largely due to apoptotic death may be induced
by the virus ( as in adenovirus and HIV infections)
4 .Pathologic atrophy in parenchymal organs after duct obstruction, such as
occurs in the pancreas , parotid gland and kidney
 MORPHOLOGIC CHANGES IN APOPTOSIS
Cell Shrinkage: Cell is smaller in size; Cytoplasm is dense;
organelles are tightly packed.

Chromatin Condensation: Chromatin aggregates peripherally,

under the nuclear membrane; nucleus may break in fragments

Formation of cytoplasmic blebs and apoptotic bodies.

Phagocytosis of apoptotic bodies by adjacent healthy cells

ON HISTOLOGIC SECTIONS: Apoptosis involves single cell or

small clusters of cells. The apoptotic cell appears
as a round or oval mass of intensely
essinophilic cytoplasm with dense nuclear
chromatin
The sequential ultra structural changes seen in coagulation necrosis (left)
& Apoptosis (right). In apoptosis, the initial changes consist of nuclear
chromatin condensation and fragmentation, followed by cytoplasmic
budding and phagocytosis of the extruded apoptotic bodies. Signs of
coagulation necrosis include chromatin clumping, organellar swelling,
and eventual membrane damage.
A. Apoptosis in the skin in an immune-mediated
reaction. The apoptotic cells are visible in the epidermis
with intensely eosinophilic cytoplasm and small dense
nuclei.
B. High power view of apoptotic cell in the lever in
immune-mediated hepatic cell injury.
Apoptosis: Apoptotic cells (some indicted by
arrows) in a normal crypt in the colonic
epithelium.
Note the fragmented nuclei with condensed
chromatin and the shrunken cell bodies ,
some with pieces falling off
Apoptosis: More orderly process of cell death; there is individual cell
necrosis , not necrosis of large number of cells. In this example the
Liver cells are dying individually (arrows) from injury by Viral
Hepatitis . The cells are pink and without nuclei
Apoptosis of a liver cell in viral hepatitis. The cell is reduced in size and contains
brightly eosinophilic cytoplasm and a condensed nucleus
 DYSREGULATED APOPTOSIS
(“too little or too much’)
Disorders associated with reduced apoptosis: An
inappropriately low rate of apoptosis may prolong survival of
abnormal cells. These accumulated cells then give rise to
a) Cancers, especially those carcinomas with p53 mutations
b) Autoimmune disorders, which could arise, if autoreacitve
lymphocytes are not removed after immune response.

Disorders associated with increased apoptosis. These

disorders are characterized by a marked loss of normal or protective
cells and include :
a) Neurodegenerative diseases
b) Virus – induced lymphocyte depletion
c) Aplastic Anaemia
 Apoptosis: Summary

 Individual cell deletion in physiological growth control and in

disease.
 Activated or prevented by a variety of stimuli.
Reduced apoptosis contributes to cell accumulation, e.g. neoplasia
 Increased apoptosis results in excessive cell loss, e.g. atrophy


 COMPARISON OF CELL DEATH BY APOPTOSIS & NECROSIS
FEATURE APOPTOSIS NECROSIS
Cell Suicide Cell Homicide
Induction May be induced by Invariably due to pathological
physiological or pathological injury
stimuli

Extent Single cells Cell groups

Biochemical events (I) Energy- dependent (i) Impairment or cessation of

fragmentation of DNA by ion homeostasis
endogenous endonucleases (ii) Lysosomes leak lytic
(ii) Lysosomes intact enzymes
Cell membrane Maintained Lost
integrity
Morphology Cell fragmentation to form Cell swelling and lysis
apoptotic bodies

Inflammatory None Usual

response
Fate of dead cells Ingested by neighbouring Ingested by neutrophils and
cells macrophages
Mechanisms
of
Cell
Injury
 Principles underlying most forms of cell injury

 Mechanisms linking any given injury with the

resulting cellular and tissue manifestations are
complex, interconnected and tightly interwoven
with many intra-cellular metabolic pathways .

 It is difficult to pinpoint specific molecular

alterations. But several general principles are there
 Principles underlying most forms of cell injury

1. The cellular response to injurious stimuli depends

on the type of injury, its duration, and its severity

2. The consequences of an injurious stimulus depend on

the type, status, adaptability and genetic makeup of the
injured cell.

3. Cell injury results from functional and biochemical

abnormalities in one or more of several essential cellular
components
 Most important targets of injurious stimuli

(1)Mitochondria, the site of ATP generation

(2)Cell Membrane, on which the ionic and osmotic

homeostasis of the cell and its organelles depends

(4) Protein synthesis

(5) Cytoskeleton

(6) Genetic apparatus of the cell

 Principal cellular and biochemical sites of damage in cell injury

(1) (2) (3) (4)

Principal targets and biochemical mechanisms of cell injury are:

(1) Mitochondria and their ability to generate ATP and reactive oxygen
species under pathologic conditions
(2) Disturbance in Calcium homoestasis
(3) Damage to cellular (plasma and lysosomal )membranes
(4) Damage to DNA and misfolding of proteins
 Depletion of ATP

High energy phosphate in the form of ATP is required

for many synthetic and degredative processes within
the cells. These include :
(i) Membrane transport
(ii) Protein Synthesis
(iii) Lipogenesis
(iv) Deacylation – reacylation reactions necessary for
phospholipids turnover
 Consequences of Decreased ATP

Depletion of ATP to less than 5% to 10% of normal levels

has widespread effects on many critical cellular systems:
The activity of plasma membrane energy dependent sodium
pump is reduced, resulting in intracellular accumulation of
sodium and efflux of potassium. The net gain of solute is accompanied
by iso – osmotic gain of water, causing cell swelling and dilation of
endoplasmic reticulum
Compensatory increase in anaerobic glycolysis in an attempt to maintain
the cell’s energy sources.
Failure of calcium pump leads to influx of Ca++ , with damaging effects
on numerous cellular components.
Structural disruption of the protein synthetic apparatus manifested as
detachment of ribosomes from the rough endoplasmic reticulum and
dissociation of polysomes into monosomes, with a consequent reduction
in protein synthesis.

Ultimately, there is irreversible damage to mitochondrial

and lysosomal membrane s. and the cell undergo necrosis
The initial functional and morphologic consequences of decreased
intracellular adenosine triphosphate (ATP) during cell injury
 ROLE OF MITOCHONDRIA IN CELL INJURY

● Directly or indirectly , mitochondria are

important targets for virtually all types of
injurious stimuli, including hypoxia and
toxins.

● Mitochondria can be damaged by:

(i) Increase in cytosolic Ca++
(ii) Oxidative stress
(iii) Breakdown of phospholipids through the
phospholipase A2
 Consequences of Mitochondrial damage

Two major consequences of mitochondrial damage:

1) Mitochondrial damage results in the formation of a high
conductance channel in the mitochondrial membrane, called
the “mitochondrial permeability transition pore”. The opening
of this channel leads to the loss of mitochondrial membrane
potential and pH changes, resulting in failure
of oxidative
phosphorylation and progressive depletion
of ATP, culminating in necrosis of cell
2) Increased permeability of mitochondrial membrane leads to
release of enzymes having an active role in Apoptosis
(cytochrome –C) . It may lead to death by Apoptosis
Consequences of
mitochondrial dysfunction,
culminating in cell death by
necrosis or apoptosis
 Defects in Membrane Permeability
 Early loss of selective membrane permeability leading
ultimately to overt membrane damage is a consistent feature
of most forms of cell injury (except apoptosis).

 The plasma membrane can be damaged by:

1. Ischemia
2. Microbial toxins
3. Lytic complement components
4. Physical and chemical agents

 Different biochemical mechanisms may contribute to

membrane damage:
1. Decreased phospholipids synthesis
2. Increased phospholipids breakdown
3. Reactive Oxygen species
4. Cytoskeletal abnormalities
5. Lipid breakdown products
 Mechanisms of Membrane Damage in cell Injury

Decreased O2 and increased cytosolic Ca 2+ are typically seen in ischemia

but may accompany other forms of cell injury.
Reactive oxygen species (not shown in figure), which are often produced
on reperfusion of ischemic tissues, also cause membrane damage
 Important sites of membrane damage
during cell injury

1. Mitochondrial Membrane Damage: It leads to decreased

production of ATP, culminating in necrosis and release of
proteins that trigger apoptotic death

2. Plasma Membrane Damage: Plasma membrane damage

leads to loss of osmotic balance and influx of fluids and
ions, as well as loss of cellular contents

3. Injury to Lysosomal Mmebranes: it results in leakage of

their enzymes into the cytoplasm which leads to enzymatic
digestion of cell components .
 ROLE OF CALCIUM INFLUX

Toxins or ischemia allow a net influx of extra

cellular calcium across the plasma membrane,
followed by release of calcium from the
intracellular stores
Increased cytosolic calcium activates different
enzymes:
(i) Phospholipases: Promote membrane damage
(ii) Proteases: Catabolize structural and
membrane proteins
(iii) ATPases: Accelerate ATP depletion
(iv) Endonucleases: Fragment genetic material
Sources and Consequences of increased Cytosolic
Calcium in cell injury
Increased Ca ++ levels also result in the induction of
apoptosis, by direct activation of caspases and by
increasing mitochondrial permeability
FREE RADICAL MEDIATION OF CELL INJURY
 Free radicals are chemical species with a single
unpaired electron in their outer orbit and therefore highly
reactive
Such chemical states are extremely unstable and readily
react with inorganic or organic chemicals

The excess energy attributable to the unstable

configuration is released through chemical reactions with
adjacent molecules.
One of the best known reactions is that between oxygen
based free radicals and cell membrane lipids (lipid
peroxidation) which leads to membrane damage.

 Free radicals , when generated in cells they attack and

degrade nucleic acids, as well as a variety of membrane
molecules ;

Molecules that react with free radicals, are in turn

converted into free radicals, further propagating the chain
of damage.
 IMPORTANT FREE RADICALS
1. Hydroxyl (OH -) and Hydrogen (H - ) free radicals generated from
hydrolysis of water through ionizing radiation.
2. Super oxide radical generated from oxygen
3. Fe+++ generated during Fenton reaction

MECHANISM OF INJURY BY FREE RADICALS

1. Lipid peroxidation of membranes
2. Lesions in deoxyribonucleic acid (DNA)
3. Cross linking of proteins

CELLULAR ANTIOXIDANT MECHANISM

1. Glutathione peorxidase
2. Catalse
3. Superoxidase Dismutase
4. Vitamin E
5. Vitamin C
Oxygen induced free radicals
 Generation of free radicals

A, Top: Generation of free radicals

B, bottom left : the cell injury resulting from the action of unopposed free radicals
C, bottom right : Free radicals neutralization by cellular antioxidants
 Three important Free Radicals Generated
effects
1. Membrane lipid peroxidation
2. DNA fragmentation
3. Protein cross linking and fragmentation
 The role of reactive oxygen species in cell injury

O2 is converted to superoxide by oxidative

enzymes in the endoplasmic reticulum,
Mitochondria, plasma membrane,
perioxisomes and cytosol. Superoxide
is converted to H2O2 by dismutation
and thence to OH - by the Cu2+/Fe2+
catalyzed Fenton reaction. H2O2 is also
directly derived from oxidases
in perioxisomes not shown in figure.
Also not shown a potentially toxic
free radical singlet oxygen. Resultsant
free-radical damage to lipid
(by peroixdation), proteins and DNA
leads to various forms of cell injury.
 FREE RADICAL & CELL INJURY
Various Agents that produce Free Radicals
Ionizing Radiation
Chemical Oxidants
Oxygen Therapy
Acute Inflammation (Granulocytes)
Chemical Poisons (Carbon tetrachloride)

Free Radical Produced

Super oxide; Hydroxyl Radical; Free Hydrogen Radical ; Hydrogen Peroxide

Effects of Free Radicals

Lipid Per oxidation of Cell Membrane
Lipid Peorxidation of Mitochondrial Membranes
Breakdown of DNA
Cross linking of Proteins
 Examples of Free Radical Induced Injury
1. Ischemia- reperfusion

2. Chemical injury

3. Radiation injury

4. Toxicity of Oxygen and other gases

5. Cellular aging

6. Microbial killing by phagocytic cells

7. Tissue injury caused by inflammatory cells

Removal of Free Radicals
Free radicals are inherently unstable and
decay spontaneously

There are non-enzymatic and enzymatic

systems which contribute to inactivation
of free radicals
Intracellular
Accumulations
 INTRACULLAR ACCUMULATIONS
One of the manifestations of metabolic derangements in cells
is the intracellular accumulation of abnormal amounts of
various substances
The stockpiled substance fall into three categories:

(I) A normal cellular consistent accumulates in excess

a. Fatty change liver
b. Haemosidrosis
c. Bilirubin accumulation
(II) A normal or abnormal substance, accumulates because of the
genetic or acquired defects to metabolize it:
a. Glycogen Storage diseases
(III) An abnormal exogenous substance accumulates because body
can not metabolize it (PIGMENTATION)
a. Accumulation of carbon particles in lungs
b. Tattooing
(IV) Specialized Accumulations
a. Calcification
b. Amyloidosis
(i) A normal endogenous substance is produced at a
normal or increased rate, but the rate of
metabolism is inadequate to remove it
Example: Fatty Change of Liver
 Fatty Change of Liver
The term Steatosis and Fatty Change describe abnormal
accumulation of triglycerides within parenchymal cells.
Fatty change is often seen in the liver because it is the
major organ involved in the fat metabolism, but it also
occurs in heart, muscle, and kidney
The causes of fatty change include:
(i) Toxins.
(ii) Protein malnutrition.
(iii) Diabetes mellitus.
(iv) Obesity.
(v) Anorexia
(vi) Alcohol abuse ( In industrialized world it is
the most common cause)
Possible mechanisms leading to
Accumulation of triglycerides in
Fatty liver: Defects in any six
Numbered steps of uptake,
Catabolism, or secretion can
Result in Lipid Accumulation
1. Excessive entry of free fatty acids in liver
2Excess acetate
.3.Excessive oxidation to ketone bodies
4.Excessive release of alpha-glycerophoshate
which inturn leads to increased trigylcerides
formation
5.Decreased apoprotein incorporation in
triglycerides
6. Decreased synthesis of lipoprotiens

 In different disease states, which lead to fatty change, any of

these mechanisms can be involved
 Alcohol virtually effects most of these
Mechanisms involved in triglycerides accumulation in liver:
•Free fatty acids from adipose tissues or ingested foods are normally
transported into hepatocytes. In liver they are :
- Estrified to triglycerides
- converted to cholestrol or phospholipids
- Oxidized to ketonebodies
• Some fatty acids are synthesized from acetate as well.
• Release of triglycerdies from hepatocytes requires association with
Apoproteins to form lipoproteins.
• Lipoproteins then enter into circulation.
Excess accumulation of triglycerdies can result within the liver
may result from defects in any of the events in the sequence from
fatty acid entery to lipoprotein exit
Alcohol: A hepatotoxin that alters mitochondrial and microsomal functions
Protein malnutrition: Act by decreased synthesis of lipoproteins
Starvation: Increased fatty acids mobilization from peripheral tissues
High power detail of Fatty changeIn liver:
In most cells well preserved. Nucleus is squeezed into the
displaced rim of cytoplasm about the fat vacuole
 Fatty Change Liver

Intracellular accumulation of a variety of materials can occur in response

to cellular injury. Here is fatty metamorphosis (Fatty change) of the liver
in which deranged lipoprotein transport from injury (most often
Alcoholism) leads to accumulation of lipid in the cytoplasm of
hepatocytes.
Fatty liver
Slide No 4
Section in the liver shows:
Empty fat vacuoles in the
cytoplasm of the liver cells
The vacuoles had dissolved in
xylol during preparation.
•The nuclei of the liver cells
are pushed against the cell
membrane and become
flattened giving the cell signet
ring appearance.
•Diagnosis:
Fatty Liver
 Cholesterol and Cholesterol Esters accumulation
Most cells use cholesterol for cell membrane synthesis, without
intracellular accumulation of cholesterol esters.
In several pathologic conditions intracellular accumulation of cholesterol
can be manifested

Atherosclerosis: In atherosclerotic plaques smooth muscle cells and

macrophages are filled with fat vacuoles most of which are made of
cholesterol and cholesterol esters ( Foam Cells)
Xanthomas: In hereditary and acquired hyperlipedimic states clusters of
foam cells are found in the sub epithelial connective tissue of the skin
and tendons producing tumourous masses known as Xanthomas
Inflammation and Repair: Foamy macrophages are frequently found at
sites of cell injury and inflammation , owing to phagocytosis of
cholesterol from membranes of injured cells
Cholesterolosis: This refers to focal accumulation of cholesterol – laden
macrophages in the lamina propria of gall bladder,
Cholesterol and Cholesterol Esters accumulation
Atheroma
Xanthomas
 Proteins accumulation
•Protein appears as eosinophilic droplets in the cytoplasms
• In certain disorders excessive accumulation of protein
takes place:
Reabsorption droplets in proximal renal tubules: Seen in
renal diseases associated with protein loss in the urine
(Proteinuria)
Excessive synthesis of proteins: occurs in plasma cell
dyscrasisias like Multple Myeloma where there is excessive
immunoglobulin synthesis
Amylodosis:
Multiple myeloma-Plasma Cells With
Inclusions
 Glycogen accumulation
•Excessive intracellular accumulation of glycogen are seen
in patients with an abnormality in either glucose or glycogen
metabolism .
Diabetes mellitus: It is the prime example of a disorder of
glucose metabolism
Glycogen storage diseases: A group of genetic disorders , In
these enzymatic defects in glycogen synthesis or breakdown
leads to excessive accumulation of glycogen in cells
 Special stains to demonstrate intracellular
accumulations
Special stains to demonstrate fat:
-Sudan IV
- Oil Red O
Special stains to demonstrate Glycogen:
- PAS stain
- Sudan Black B
2. A normal or abnormal substance accumulates because
of genetic or acquired defects in the metabolism,
packaging, transport, or secretion
of these subsrtances

Examples:
Storage Diseases: Genetic defects of specific enzymes involved in the
metabolism of lipids and carbohydrates leads to intracellular
deposition of these substances.
 Niemann Pick Disease

Bone marrow aspirate showing a Niemann pick cell. Monocytes

with foamy appearance of cytoplasm due to lipid vacuoles
 Gaucher Disease

Bone marrow aspirate showing Gaucher cells. Monocytes with pale

blue cytoplasm and round to oval nuclei. Cytoplasm appear fibriller
These disorders are also called familial sphingolipidoses, since
inherited
. deficiency of certain enzymes ( glucoceribrosidase in
Gaucher’s disease and sphingomylinase in Niemenn Pick disease )
required for the catabolism of lipid compounds lead to the
accumulation of these lipids and polysaccharides.
The stock-pilled substance is mainly accumulated in the
macrophages. Accumulation of these lipid- laden
macrophages in the blood, bone marrow, spleen, liver and other
organs leads to manifestations like anaemia, leucopenia,
thrombocytopenia and hepato-splenomegaly.
3. An abnormal exogenous substance is deposited because the cell
has neither the enzymatic machinery to degrade the substance nor
the ability to transport to other sites
Example: Accumulation of Carbon particles in lungs
Calcification
 CALCIFICATION
•Calcification is the abnormal deposition of Calcium
salts, at sites other than osteoid and enamel along
with smaller amounts of iron, magnesium and other
mineral salts
•Calcification is of two types:
1. Dystrophic Calcification: Deposition in dead or
dying tissue
2. Metastatic Calcification: Deposition in living
tissue
DYSTROPHIC METASTATIC
CALCIFICATION CALCIFICATION

Deposition of calcium Deposition of calcium

in dead or dying tissue in living tissue

Not associated with Associated with

abnormalities in abnormalities in
calcium metabolism calcium metabolism
Hypercalcemia absent Hypercalcemia present
Dystrophic calcification: Examples
1. In areas of necrosis. The necrosed tissue can get converted
in a calcified mass
2. The atheromas of advanced atherosclerosis.
3. Aging or damaged heart valves
4. Aged pineal gland.
5. Dead parasites
6. Dead retained fetus.
7. Dystrophic Calcification can be seen in carcinomas. For
example “Psammoma bodies” seen in capillary carcinoma
of thyroid.
Aortic valve in a heart with calcific aortic stenosis. The
semilunar cusps are thickened and fibrotic . Behind each
cusp are seen irregular masses of pilled- up dystrophic
calcification
 Dystrophic calcification

Aortic valve calcification

 Dystrophic Calcification

This is dystrophic calcification in the wall of the stomach. At the far

left is an artery with Calcification in its wall. There are also irregular
bluish – purple deposits of calcium in the sub mucosa . Calcium
is more likely to be deposited in the tissues that are damaged.
 Psamomma Bodies- Dystrophic
Calcification Seen in
Malignant Tumours

Psamomma Bodes: Are lamellated bodies of

dystrophic calcification.
Seen in:
-Papillary carcinoma thyroid
-Meningioma
Serous ovarian malignant tumours
Pathogenesis of Dystrophic Calcification

Initiation
Calcium from mitochondria

Calcium combines with Phospholipids in

cell membrane

Membrane associated phosphatases generate phosphate

groups that bind to bound calcium

Propagation
Cycle of Calcium and Phosphate binding is repeated again
and again

Micro crystals develops after a rearrangement

in the phosphate and calcium ions

Dystrophic Calcification
 Model of membrane facilitated calcification: calcium ions bind the
phospholipids present in a membrane. Membrane associated
phopshateses generate phosphate groups that bind to that bind to the
bound calcium.The cycle of phosphate and calcium binding is repeated,
increasing the size of deposit. A micro crystal develops after a
rearrangement in the phosphate and calcium ions
 Metastatic Calcification: Examples
There are four principal causes in groups of patients with
Hypercalcemia who can have Metastatic Calcification:
1. Increased secretion of Parathyroid Hormone with subsequent
bone resorption seen in
a. Hyperparathyroidism due to parathyroid tumours
b. Ectopic secretion of Parathyroid hormone by
malignant tumours
2. Destruction of bone tissue seen with
a. primary tumours of bone marrow like:
- Multiple Myeloma
- Leukaemias
b. Diffuse skeletal metastasis (e.g., breast cancer)
c. Accelerated bone turn over like in Paget disease or in
immobilization.
3. Renal Failure , which causes retention of Phosphate, leading
to secondary hyperparathyroidism.
4. Vitamin – D related disorders including Vitamin- D
intoxication and Sarcoidosis.
 Calcification: Morphology
 Regardless of the site , calcium salts are seen on gross examination
as fine white granules or clumps.
 Often felt as gritty deposits
 Dystrophic calcification is common in areas of caseous necrosis
 On histologic examination calcification appears as intracellular and/or
 extracellular basophilic deposits .
 Overtime , hetrotropic bone may be formed in the focus of calcification
 Metastatic calcification can occur widely throughout the body but
principally affects the interstitial tissues of the vasculature ,kidneys,
lungs and gastric mucosa.
 Calcium deposits, in metastatic calcification, morphologically
resemble those as in dystrophic calcification .
 Metastatic Calcification

Metastatic calcification in the lung of a patient with a

very high serum Calcium level (Hyperplasia)
Metastatic calcification, lung
Pigments
 PIGMENTS
Pigments are colured substances which
accumulate in cells.
Based on the source pigments can be of two types

1. Exogenous pigments

2. Endogenous pigments
 PIGMENTS
(I) Endogenous Pigments
1.Lipofuscin
2. Melanin
3. Bilirubin
4. Haemosidrin
(II) Exogenous Pigments
1. Anthracosis
2. Pneumoconiosis
3. Tattoing
 (i) ENDOGENOUS PIGMENTS

These are the pigments which are synthesized inside the body
a. Lipofuscin or Wear and tear pigment: It is composed of
polymers of lipid and phospholipids complexed with proteins ,
suggesting that it is derived through lipid peroxidation of
polyunsaturated lipids of sub cellular membranes. It is the tell tale
sign of free radical injury.
Microscopic appearance: Yellow brown intracytoplasmic granules.

b. Melanin: Brown black pigment derived from melanocytes of

skin. Examples of melanin accumulation;
- Suntan
- Melasma
- In pregnancy
c. Haemosidrin: Golden yellow to brown granular pigment . It is
the form in which iron is accumulated in cells.
The main storage form of iron is ferritin. But when there is
local or systemic excess of iron, ferritin aggregates in the form of
haemosidrin.
Haemosidrosis ( increased sysmteimic accumulation of iron)
is seen in:
(i) Increased absorption of dietary iron.
(ii) Impaired use of iron.
(iii) Haemolytic anaemias , for example beta thalassaemia
major
(iv) Repeated blood transfusions.

d. Bilirubin: Jaundice is the common clinical disorder caused by

excesses of Bilirubin within cells and tissues.
 Lipofuscin Accumulation

The yellow brown granular pigment seen in the hepatocytes here is

Lipochrome (LIpofuscin) which accumulates over time in cells (particularly
liver and heart) as a result of “wear and tear” with aging . It is of no major
consequence , but illustrates the end result of the process of autophago-
cytosis in which intracellular debris is sequestered and turned into these
residual bodies of lipochrome within the cell cytoplasm
Endogenous pigment

Liver haemosiderosis
Haemosidrosis: Brown coarsy granular material in macrophages in
alveoli is hemosidrin that has accumulated as a result of breakdown
of red blood cells
Haemosidrin: Prussian Blue Reaction (Iron stain) of liver showing
large amount of hemosidrin in Hepatocytes and Kuppfer cells
 Haemosidrin deposition in Kidney

Renal tubules contain large amount of haemosidrin, as demonstrated by

Prussian Blue Iron Stain. This patient had intravascular haemolysis
 Jaundice

The Sclera of the eye is yellow because the patient has jaundice,
or Icterus. The normally white sclera of the eyes is a good place on
physical examination to look for jaundice.
Bilirubin: Yellow – green globular material seen in
small bile ductules in liver
 Haemosidrin granules in liver cells

A: H& E showing golden brown , finely granular pigment

B: Prussian Blue , specific for iron
Suntan
Melasma
 (ii) EXOGENOUS PIGMENTS

These are the pigments which come from outside the body.
Anthracosis (Carbon or coal dust accumulation): It is the main
pollutant of the urban life. When inhaled, it is picked up by
macrophages within the alveoli and is then transported through
lymphatic channels to regional lymph nodes. Accumulation of this
pigment blackens the tissues of lung ( Anthracosis).

b. Coal worker’s pneumoconiosis: In coal miners and those living in

heavily polluted environments , the aggregates of carbon dust may
induce a fibroblastic reaction or even emphysema and thus cause a
serious lung disease known as coal worker’s pneumoconiosis.

c. Tattooing: A form of localized exogenous pigmentation. The pigments

inoculated are ingested by dermal macrophages, where they reside
permanently .
Anthrocosis pigment in macrophages in hilar lymph node:
Anthrocosis is accumulation of carbon pigment from breathing
bad sir. Smokers have the most pronounced Anthrocosis.
Exogenous pigment

Anthracosis of lung
Tattooing
Endogenous substances accumulating in tissues as a result of
deranged metabolism
Accumulated Effects in Effects in
Substance Parenchymal cells interstitial cells
Water Cloudy swelling Edema
Hydropic changes
Triglycerides Fatty change
Cholesterol Atherosclerosis
Xanthomas
Complex lipids Lipid storage diseases

Protein -Ubiquitin/ Protein Amylodosis

complexes
Glycogen Glycogen storage
diseases
Mucopolysaccharides Mucopolysaccharidoses Myxoid degeneration
Endogenous substances accumulating in tissues as a result of
deranged metabolism
Accumulated Effects in Effects in
Substance Parenchymal cells interstitial cells
Iron Hemochromatosis Localized
Haemosidrosis
Calcium Contributes to necrosis Calcification
Copper Wilson’s disease Wilson’s disease

Bilirubin Kernicterus Jaundice

Lipofuscin Brown Atrophy in old

age
Urate Gout

Homogensitic Acid Alkaptonuria

 Cell
Ageing
 Cell Ageing
•A number of cellular functions decline progressively with age

•With advancing age there is progressive accumulation of

sublethal injury that comprises cellular accumulation of
sublethal injury that comprises cellular function and may lead
to cell death, or at least to diminished capacity of cells to
respond to injury.
 A number of cellular functions decline with age:
Mitochondrial oxidative phospohorylation is reduced

Synthesis of structural, enzymatic and receptor proteins

is reduced.
Capacity for nutrients uptake is diminished.

Capacity to repair chromosomal damage is jeopardized.

 All these leads to morphologic alterations
in senescent cells like:
Irregular nuclei
Pleomorphic cytoplasmic vacuolations
Distorted Golgi apparatus
Steady accumulation of Lipofuscin pigemnts(
indicating past oxidative damage and membrane injury)

“Lipofuscin Pigment” OR “Lipochrome Pigment” OR

“Wear and Tear Pigment” OR “Ageing Pigment” OR
“Free Radical Induced Pigment”
 Lipofuscin Accumulation

The yellow brown granular pigment seen in the hepatocytes here is

Lipochrome (LIpofuscin) which accumulates over time in cells (particularly
liver and heart) as a result of “wear and tear” with aging . It is of no major
consequence , but illustrates the end result of the process of autophago-
cytosis in which intracellular debris is sequestered and turned into these
residual bodies of lipochrome within the cell cytoplasm
Lipofuscin granules in cardiac myocyte
 Hypotheses about cell ageing

1. Inbuilt genetic mechanisms

( Clonal Senescence Theory)

2. Wear and Tear mechanisms

( Replication Senescence)

3. Telomere Shortening
Mechanisms of cell aging .Among the several pathways contributing
to aging of cells and organisms many have been defined in
simple model organisms ,and their relevance to aging in
humans remains area of active investigation.
Suggested cellular mechanisms of ageing and death: There is direct or
circumstantial evidence supporting each of the mechanisms illustrated.
Some mechanisms interact with others; for example , free radicals may be
responsible for DNA mutations .
 Inbuilt Genetic Mechanisms
(Clonal Senescence Theory)

Common experience supports the idea that there is an

inbuilt ‘allotted life- span’ for humans and animals .

It is clear that cellular senescence is multifactorial . It

involves the cumulative effects of both an intrinsic
molecular clock of cellular aging and the extrinsic
stressors of the cellular environment .
 Wear and Tear Mechanisms
Replication Senescence

•Due to vicissitudes of daily life and due to the accumulation of sublethal

damage in cells there is system failure of sufficient magnitude that the whole
organism succumbs
•The common pathway resulting in cellular deterioration is currently
thought to be the generation of highly reactive molecular species – ‘free
radicals’
•With advancing age there is decreased formation of ‘antioxidants’ , so
defense against free radical induced injury becomes weak with advancing
age
•Accumulation of Lipofuscin or aging pigment in old age is a tell tale sign
of free radical induced injury.
Defective DNA Repair: There are mechanism in the cell that deals with
damage, particularly DNA damage. With advancing this repair mechanims
become weak.
 Telomere Shortening
At the tip of each chromosome there is a non – coding
tandemly repetitive DNA sequence , this is the telomere.
These telomric sequences are not fully copied during
DNA synthesis prior to mitosis. As a result , a single –
stranded tail of DNA is left at the tip of each
chromosome ; this is excised and , with each cell devision
, the telomeres are shortened . Eventually the
telomeres are so short that DNA polymerase is unable to
engage in the subtelomeric start positions for
transcription and the cell is incapable of further
replication.

Telomeric shortening could explain the replication limit

of cells. This is supported by the finding that telomric
length decreases with age of individual.
Telomeres, telomerase and
replicative capacity: Telomeres are
Essential for chromosomal copying
during the S- phase of cell cycle.
However , most Somatic cells lack
telomerase (the enzymes that
regenerates telomeres)
so the telomeres shorten with each
Cell division until chromosomal
copying become impossible.
Germ cells and some neoplastic
cells express telomerase and thereby
have extended replicative capacity.
 Mechanisms of Cellular Injury

Mechanisms that cause and counteracts cellular aging. DNA damage,

replicative senescence and decreased and misfolded proteins are
among the best described mecahnisms of cellular aging .
Some envirnmental stresses, such as calorie restriction, counteract aging
by activating various signaling pathways and transcription factors
 The Role of Telomeres and telomerase in
Replicative Senescence of cells

In normal somatic cells there is no

telomerase activity, and telomeres
progressively shorten with
increasing cell divisions until
growth arrests, or senescence,
occurs.
 Germ cells, and stem cells both
contain active telomerase, but
only the germ cells have
sufficient levels of the enzyme
to stabilize telomere length
completely.
In cancer cells, telomerase is
often reactivated.

Telomere length is plotted against

the number of cell divisions
 RECEPTORS
&
SIGNAL
TRANSDUCTION
Dr. Zunera Hakim
 LEARNING OBJECTIVES
At the end of the session the students should be able;

• Define ligand
• Define receptors
• Identify different types of receptors
• Describe different of receptor-ligand interactions

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3
 1.Extracellular messenger
molecules (ligands/signal)
2.Receptors at target cell
3.Signal transduction pathway
4.Effectors

Cell Communication
4
(cell signaling)
 LIGAND
• Natural endogenous substances which act on
various receptors in the body

• Acetylcholine, GABA, Adrenaline, Glutamate etc

• Most drugs act by altering the activity of

ligands having either similar effects, opposite
or block effect of ligand

Orphan Receptors
 • Macromolecule or binding site located
RECEPTOR on the surface or inside the effector
cell that serves to recognize the signal
and initiate a response to it
 ❖ Most of the drugs act through
receptors in the body

• Regulatory proteins
RECEPTOR •
•
Enzymes
Transport proteins
• Structural proteins
 ❖ Intracellular receptors
• Cytoplasm (Type –I)
(androgen, glucocorticoid,
mineralocorticoid and progesterone)
• Nucleus (Type-II)
RECEPTOR (peroxisome proliferator, retinoic acid,
& thyroid receptors)
LOCATION

❖ Cell surface receptors

• Ligand gated Ion channels
• Enzyme linked receptors
• G-protein coupled receptors
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 RECEPTOR
STRUCTURE
INTRACELLULAR RECEPTOR CELL SURFACE RECEPTOR
• Ligand binding domain • External ligand binding domain
• DNA binding domain • Hydrophobic transmembrane
• Transcription activating spanning domain
domain • Intracellular domain

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 RECEPTOR &LIGAND
BINDING
• Each receptor has a
recognition site which is
specific region of the receptor
to which signal molecule binds
i) Orthosteric site
ii) Allosteric site
 RECEPTOR-LIGAND BINDING
Receptors & ligands have molecular complimentarity: i.e. the shape & chemical
properties of their binding sites are matching to permit selective binding.

11 Weak to Strong
 RECEPTOR –LIGAND BINDING
D+R D-R Complex Response

• Affinity
A measure of propensity of a drug to bind
receptor
• Intrinsic activity/efficacy
Ability of a bound drug to change the receptor
in a way that produces an effect
 RECEPTOR –LIGAND INTERACTION
Binding of a drug to a receptor can be as

• Agonist

• Antagonist

• Partial agonist

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RECEPTOR –LIGAND INTERACTION
AGONIST
• Agent having both affinity and
high intrinsic activity which
activates a receptor to produce a
maximal biological response
• E-g Adrenaline, acetylcholine
RECEPTOR –LIGAND INTERACTION
ANTAGONIST
• Agent having ONLY affinity with
NO intrinsic activity which prevents
the binding of an agonist to a
receptor
• E-g Propranolol , Atropine
RECEPTOR –LIGAND INTERACTION
PARTIAL AGONIST
• Agent having both affinity and low
intrinsic activity which activates a
receptor to produce a sub maximal
biological response
• In presence of full agonist, it acts
as antagonist
• E-g pentozocine
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 RECEPTOR REGULATION
NORMAL UP REGULATION DOWN REGULATION

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