International Journal of Current Research and Review
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IJCRR - 9(1), January, 2017

Pages: 17-21

Date of Publication: 07-Jan-2017


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PROGNOSTIC EVALUATION OF CHRONIC LIVER DISEASE PATIENTS WITH VARIOUS SCORING SYSTEMS

Author: Showkat Ahmad Malik1, Abdul Qayoom Rather2, Peerzadi Shabeena3, Waseem Raja4

Category: Healthcare

Abstract:Background: Prognostic evaluation of patients with chronic liver diseases is an important topic, often challenging the clinician. The number of patients on waiting lists for orthostatic liver transplantation (OLT) is becoming increasingly higher compared with the number of available donor livers. Correct timing of orthostatic liver transplantation can reduce the mortality of patients on waiting lists and improve post-transplantation survival.
Objective: To evaluate the short and medium term survival prognosis of chronic liver disease patients by means of various scoring systems.
Material and Methods: Our study was a hospital based retrospective study in which 93 chronic liver disease patients of either sex, age > 18 years and of any etiology were included. Medical records of these patients were retrospectively reviewed. Child-pugh, MELD, MELA-Na and updated forms of MELD and MELD-Na were calculated from data. Predictive value of survival at 3 months and 1 year were compared between scores through AUROC (Area under receiver operating characteristics and p value of < 0.05 was considered significant.
Results: 23 patients died including 4 who lost follow up, but all where belonging to Child Pugh class C and so considered dead. At both levels of assessment the scores of patient who died where significantly higher than those who survived, but there was no statistically significant difference in prediction of survival between various scores at both times as shown by their AUROC.
Conclusion: All these scoring systems are useful for predicting survival of chronic liver disease patients and so more studies are warranted to investigate the superiority of one model over others..

Keywords: Child Pugh, MELD, MELD-Na, Updated MELD-Na, AUROC

Full Text:

INTRODUCTION

The prevalence of chronic liver disease patients is increasing in the world, because of hepatitis B, C, alcoholic and non-alcoholic fatty liver disease (NAFLD), so are the patients on waiting list for orthostatic liver transplantation (OLT). Correct timing and selection for OLT can reduce the mortality and improve post-transplantation survival.1,2

Over the years many clinical and biochemical parameters have been suggested in order to accurately predict the prognosis of cirrhotic patients and correctly access their short and medium term survival. Child Pugh score is still considered the cornerstone in the prognostic evaluation of cirrhotic patients although it has some drawbacks, such as subjectivity of some clinical parameters and limited discriminatory ability.2 In 1999 United Network for Organ Sharing (UNOS) formulated the model for end stage liver disease (MELD) as an objective assessment tool.3 The present study aims to evaluate the prognostic accuracy of the Child Pugh, MELD, MELD-Na and updated forms of MELD and MELD-Na.  

MATERIAL AND METHODS

Our study was a retro-prospective hospital based study, conducted in SMHS hospital Srinagar (JandK) – a tertiary care teaching hospital. 93 patients of chronic liver disease patients of either gender, age > 18 years and of any etiology were included who visited the hospital from October 2009 to October 2010. The diagnosis of cirrhosis is confirmed on clinical, radiological and or biopsy (wherever feasible), detailed medical history, complete physical examination and laboratory tests (i.e. CBC, prothrombin time and INR, serum urea/creatinine, electrolytes, liver function tests) were performed in all patients at the time of registration and at 3 months and 1 year. Encephalopathy graded according to Zakim and Boyer (1996) classification4. Ascites diagnosed clinically and its degree evaluated by ultrasonic examination. Based on collected data various scores for each patients were calculated.

Various scores in each patients were calculated according to following equations:

MELD =  3.78 [Ln.Sr.Bil.(mg/dl)+11.2 [Ln.INR] + 9.57 [Ln.Sr.Creat.] + 6.43.

MELD-NA = MELD-Na – [0.025 x MELD x (140 – Na) + 140

Updated MELD = 9.39 [Ln.Sr.Bil.mg/dl] + 16.58 [Ln.INR] + 12.66 [Ln.Sr.Creat] + 6.43

Updated MELD-Na = Updated MELD-Na – [0.025xupdated MELD] x [140-Na] + 140

Child Pugh scoring was calculated from following patient parameters.

Serum Bilirubin (mg/dl), Sr. Albumin (g/dl), PT/INR, Presence or absence of Ascites or presence or absence of hepatic encephalopathy. Each patients was then allotted a Child class according to his or her score. Class A (5-6); Class B (7-9) and Class C (10-15) scores.

RESULTS AND OUTCOME

A total of 93 patients were enrolled, 56 were males (60.21%) and 37 were females (39.78%). 15 were belonging to Child Pugh class A, 45 Child Pugh class B, and 33 were belonging to Child Pugh class C. Most common etiology was cryptogenic (48 (51.6%) out of 93) followed by hepatitis B (26 (27.95%) out of 93), hepatitis C (10 (10.73%) out of 93), autoimmune 6 (6.45) out of 93) and least were mixed HBV and HCVG related (3.22%).

23 patients died including 4 who lost follow up, but all where belonging to Child Pugh class C and so considered dead. At both levels of assessment the scores of patient who died where significantly higher than those who survived, but there was no statistically significant difference in prediction of survival between various scores at both times as shown by their AUROC.

Comparison of Prognostic Accuracy Between Various Scores

To compare the accuracy of various scores as predictors of survival at 3 months and one year. The area under the operating characteristics curve (AUROC) was calculated. 23 patients died over study period of one year, 7 at 3 months and total of 23 at one year including those 4 who lost follow up. The AUROC of Child Pugh MELD, MELD-Na, updated MELD and updated MELD-Na were 0.799, 0.805, 0.806, 0.809 and 0.810 at 3 months and 0.714, 0.791, 0.765, 0.790 and 0.793 at one year.

The enhanced efficacy of liver transplantation as a treatment for end stage liver disease has led to a progressive discrepancy between supply and demand for donor livers. As a result, the proportion of patients dying while on the wait list has steadily increased5 in an attempt to reduce wait list mortality, a new allocation policy replacing the CTP with MELD has been adopted since 2002. Indeed, by allowing available grafts to the sick patients, the MELD system has led to a decrease in wait list mortality,6 without impairing the transplant outcome.7 Nevertheless the MELD system does not take into account important prognostic factors. In particular, the role of hyponatremia as an independent predictor of mortality has been convincingly demonstrated8 and some studies assessed the prognostic value of a new scores derived from integration of sodium in the MELD score.9,10 The applicability of sodium based MELD scoring systems in organ allocation has some limitation due to inter-laboratory variability and the potential variability of serum sodium concentration after simple therapeutic maneuvers such as administration of diuretics or intravenous hypotonic fluids or plasma volume expanders. Despite these caveats, Na based MELD scoring system represent a major advance in the prognostic assessment of patients with cirrhosis.11

To date only two studies12,13 with an adequate sample size have evaluated the impact of modified MELD score on wait list mortality, and both reported that the incorporation of Na into the MELD score may enhance prognostic accuracy. One study elaborated the MELD-Na formula on the data from the huge register of U.S. organ procurement and transplantation network14 and other proposed the UKELD score which is currently used to prioritize patients on the liver transplantation wait list in the United Kingdom.12 Recently based on the observation that Na inversely correlated with severity of cirrhosis, another score derived from the ratio between MELD and sodium concentration (MESO) has been proposed, but it was tested and validated in patients not listed for liver transplantation.15,16 Other MELD based models have also been devised that incorporate Na concentration and add either age10 or presence of ascites.17 However the addition of ascites in a MELD based score enhanced its prognostic ability only in patients with low standard MELD17, and its applicability to the entire spectrum of listed patients needs further assessment.

To the best of our knowledge, only two studies have compared the performance of different scores. However one study suffered from a small size, whereas the other enrolled patients who were rather old for liver transplantation and mostly had HBV related cirrhosis.18

Our study compared all the latest prognostic scores predicting short term and medium term survival prognosis of chronic liver disease patients, that includes Child-Pugh, MELD, MELD-Na, updated MELD and updated MELD-Na.19 The mean MELD at registration was 15.88+5, the minimal value from the survival benefit at one year has been demonstrated.20 The etiology of cirrhosis did not modify the actual survival rate of listed patients, which then allowed an assessment of the prognostic ability of scores not influenced by the etiology of liver disease. Finally, the issue of assessing the test performances in the entire spectrum of disease severity within our patients was specifically addressed.

Our discrimination analysis showed that all scores namely Child-Pugh, MELD, MELD-Na, updated MELD and updated MELD-Na predicted survival or chronic liver disease patients to same degree. The AUROC of Child Pugh, MELD, MELD-Na, updated MELD and updated MELD-Na were comparable, indicating good prognostic accuracy, so our study is in agreement with the studies of Jeong Han Kim et al (2009)19 and Laurence S et al (2009)21. Sharma et al (2009)14 recently tried to improve MELD performance by modifying the three coefficients of the formula, using data from scientific registry of transplant recipients for all listed adult candidates in the United States. However in our study updated MELD and standard MELD had comparable predictive value at 3 and 12 months. In their study such variant results could likely be explained by differences among enrolled patients.

Having found that 3 months and 12 months AUROC of Child Pugh, MELD, updated MELD and updated MELD-Na were not significantly different, so any one of these scores can be used for prognostic assessment and allocation of liver transplant in chronic liver disease patients.

CONCLUSION

All these scoring systems were useful for predicting survival rate of chronic liver disease patients. MELD has been accepted useful mainly for predicting short term prognosis of 3 months. Our results showed that it could be also useful for long term period upto 12 months. But it is difficult to conclude that updated MELD or updated MELD-Na are superior to pre-existing prognostic tools such as MELD, MELD-Na or Child-Pugh scores. So more studies are warranted to investigate superiority of one prognostic model over the other.

Acknowledgement: Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.

Source of Funding: NIL

Conflict of Interest: NIL

References:

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  17. Heuman DM, Abou-assi SG, Habib A, Williams LM, Stravitz RT, Sanyal A et al. Persistent ascites and low serum sodium identify patients with cirrhosis and low MELD scores who are at high risk for early death. Hepatology 2004; 40: 801-802.
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Awards, Research and Publication incentive Schemes by IJCRR

Best Article Award: 

One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to editor@ijcrr.com for more details.

Women Researcher Award:

This award is instituted to encourage women researchers to publish her work in IJCRR. Women researcher, who intends to publish her research work in IJCRR as the first author is eligible to apply for this award. Editorial Board members decide on the selection of women researchers based on the originality, novelty, and social contribution of the research work. The corresponding author of the selected manuscript is communicated and information is displayed on IJCRR’s website. Under this award selected women, the author is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.

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‘Emerging Researcher Award’ is instituted to encourage student researchers to publish their work in IJCRR. Student researchers, who intend to publish their research or review work in IJCRR as the first author are eligible to apply for this award. Editorial Board members decide on the selection of student researchers for the said award based on originality, novelty, and social applicability of the research work. Under this award selected student researcher is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.


Best Article Award

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A study by Muhas C. et al. entitled \"Study on Knowledge & Awareness About Pharmacovigilance Among Pharmacists in South India\" is awarded Best article for Vol 14 issue 22
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A study by Alice Alice entitled \"Strengthening of Human Milk Banking across South Asian Countries: A Next Step Forward\" is awarded Best article of Vol 14 issue 20
A study by Sathyanarayanan AR et al. entitled \"The on-task Attention of Individuals with Autism Spectrum Disorder-An Eye Tracker Study Using Auticare\" is awarded Best article of Vol 14 issue 19
A study by Gupta P. et al. entitled \"A Short Review on \"A Novel Approach in Fast Dissolving Film & their Evaluation Studies\" is awarded Best Article of Vol 14 issue 18.
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A study by Singh R. et al. entitled \"A Prospective Study to Find the Association of Astigmatism in Patients of Vernal Keratoconjunctivitis (VKC) in a Tertiary Health Care Centre in India (Vindhya Region MP)\" is awarded Best Article for Vol 14 issue 15
A Study by Humaira Tahir et al. entitled "Comparison of First Analgesic Demand after Major Surgeries of Obstetrics and Gynecology between Pre-Emptive Versus Intra-Operative Groups by Using Intravenous Paracetamol: A Cross-Sectional Study" is awarded Best Article for Vol 14 issue 14
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A Study by Vinita S & Ayushi S entitled "Role of Colour Doppler and Transvaginal Sonography for diagnosis of endometrial pathology in women presenting with Abnormal Uterine Bleeding" is awarded Best Article for Vol 14 issue 08
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A Study by Amol Sanap et al. entitled "The Outcome of Coxofemoral Bypass Using Cemented Bipolar Hemiarthroplasty in the Treatment of Unstable Intertrochanteric Fracture of Femur in a Rural Setup" is awarded Best Article Award of Vol 13 issue 24
A Study by Manoj KP et al. entitled "A Randomized Comparative Clinical Trial to Know the Efficacy of Ultrasound-Guided Transversus Abdominis Plane Block Against Multimodal Analgesia for Postoperative Analgesia Following Caesarean Section" is awarded Best Article Award of Vol 13 issue 23
A Study by Karimova II et al. entitled "Changes in the Activity of Intestinal Carbohydrases in Alloxan-Induced Diabetic Rats and Their Correction with Prenalon" is awarded Best Article of Vol 13 issue 22
A Study by Ashish B Roge et al. entitled "Development, Validation of RP-HPLC Method and GC MS Analysis of Desloratadine HCL and It’s Degradation Products" is awarded Best Article of Vol 13 issue 21
A Study by Isha Gaurav et al. entitled "Association of ABO Blood Group with Oral Cancer and Precancer – A Case-control Study" is awarded Best Article for Vol 13 issue 20
A Study by Amr Y. Zakaria et al. entitled "Single Nucleotide Polymorphisms of ATP-Binding Cassette Gene(ABCC3 rs4793665) affect High Dose Methotrexate-Induced Nephrotoxicity in Children with Osteosarcoma" is awarded Best Article for Vol 13 issue 19
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A Study by Bhat Asifa et al. entitled "Efficacy of Modified Carbapenem Inactivation Method for Carbapenemase Detection and Comparative Evaluation with Polymerase Chain Reaction for the Identification of Carbapenemase Producing Klebsiella pneumonia Isolates" is awarded Best Article for Vol 13 issue 17
A Study by Gupta R. et al. entitled "A Clinical Study of Paediatric Tracheostomy: Our Experience in a Tertiary Care Hospital in North India" is awarded Best Article for Vol 13 issue 16
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A Study by Purushottam S. G. et al. entitled "Development of Fenofibrate Solid Dispersions for the Plausible Aqueous Solubility Augmentation of this BCS Class-II Drug" is awarded Best article for Vol 13 issue 10
A Study by Kumar S. et al. entitled "A Study on Clinical Spectrum, Laboratory Profile, Complications and Outcome of Pediatric Scrub Typhus Patients Admitted to an Intensive Care Unit from a Tertiary Care Hospital from Eastern India" is awarded Best Article for Vol 13 issue 09
A Study by Mardhiah Kamaruddin et al. entitled "The Pattern of Creatinine Clearance in Gestational and Chronic Hypertension Women from the Third Trimester to 12 Weeks Postpartum" is awarded Best Article for Vol 13 issue 08
A Study by Sarmila G. B. et al. entitled "Study to Compare the Efficacy of Orally Administered Melatonin and Clonidine for Attenuation of Hemodynamic Response During Laryngoscopy and Endotracheal Intubation in Gastrointestinal Surgeries" is awarded Best Article for Vol 13 issue 07
A Study by M. Muthu Uma Maheswari et al. entitled "A Study on C-reactive Protein and Liver Function Tests in Laboratory RT-PCR Positive Covid-19 Patients in a Tertiary Care Centre – A Retrospective Study" is awarded Best Article of Vol 13 issue 06 Special issue Modern approaches for diagnosis of COVID-19 and current status of awareness
A Study by Gainneos PD et al. entitled "A Comparative Evaluation of the Levels of Salivary IgA in HIV Affected Children and the Children of the General Population within the Age Group of 9 – 12 Years – A Cross-Sectional Study" is awarded Best Article of Vol 13 issue 05 Special issue on Recent Advances in Dentistry for better Oral Health
A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" is awarded Best Article of Vol 13 issue 06
A Study by Chen YY and Ghazali SRB entitled "Lifetime Trauma, posttraumatic stress disorder Symptoms and Early Adolescence Risk Factors for Poor Physical Health Outcome Among Malaysian Adolescents" is awarded Best Article of Vol 13 issue 04 Special issue on Current Updates in Plant Biology to Medicine to Healthcare Awareness in Malaysia
A Study by Kumari PM et al. entitled "Study to Evaluate the Adverse Drug Reactions in a Tertiary Care Teaching Hospital in Tamilnadu - A Cross-Sectional Study" is awarded Best Article for Vol 13 issue 05
A Study by Anu et al. entitled "Effectiveness of Cytological Scoring Systems for Evaluation of Breast Lesion Cytology with its Histopathological Correlation" is awarded Best Article of Vol 13 issue 04
A Study by Sharipov R. Kh. et al. entitled "Interaction of Correction of Lipid Peroxidation Disorders with Oxibral" is awarded Best Article of Vol 13 issue 03
A Study by Tarek Elwakil et al. entitled "Led Light Photobiomodulation Effect on Wound Healing Combined with Phenytoin in Mice Model" is awarded Best Article of Vol 13 issue 02
A Study by Mohita Ray et al. entitled "Accuracy of Intra-Operative Frozen Section Consultation of Gastrointestinal Biopsy Samples in Correlation with the Final Histopathological Diagnosis" is awarded Best Article for Vol 13 issue 01
A Study by Badritdinova MN et al. entitled "Peculiarities of a Pain in Patients with Ischemic Heart Disease in the Presence of Individual Combines of the Metabolic Syndrome" is awarded Best Article for Vol 12 issue 24
A Study by Sindhu Priya E S et al. entitled "Neuroprotective activity of Pyrazolone Derivatives Against Paraquat-induced Oxidative Stress and Locomotor Impairment in Drosophila melanogaster" is awarded Best Article for Vol 12 issue 23
A Study by Habiba Suhail et al. entitled "Effect of Majoon Murmakki in Dysmenorrhoea (Usre Tams): A Standard Controlled Clinical Study" is awarded Best Article for Vol 12 issue 22
A Study by Ghaffar UB et al. entitled "Correlation between Height and Foot Length in Saudi Population in Majmaah, Saudi Arabia" is awarded Best Article for Vol 12 issue 21
A Study by Siti Sarah Binti Maidin entitled "Sleep Well: Mobile Application to Address Sleeping Problems" is awarded Best Article for Vol 12 issue 20
A Study by Avijit Singh"Comparison of Post Operative Clinical Outcomes Between “Made in India” TTK Chitra Mechanical Heart Valve Versus St Jude Mechanical Heart Valve in Valve Replacement Surgery" is awarded Best Article for Vol 12 issue 19
A Study by Sonali Banerjee and Mary Mathews N. entitled "Exploring Quality of Life and Perceived Experiences Among Couples Undergoing Fertility Treatment in Western India: A Mixed Methodology" is awarded Best Article for Vol 12 issue 18
A Study by Jabbar Desai et al. entitled "Prevalence of Obstructive Airway Disease in Patients with Ischemic Heart Disease and Hypertension" is awarded Best Article for Vol 12 issue 17
A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award


A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award


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International Journal of Current Research and Review (IJCRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal

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