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IJCRR - 12(7), April, 2020

Pages: 01-09

Date of Publication: 07-Apr-2020


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Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study

Author: Virendra Atam, Avirup Majumdar, Kamal Kumar Sawlani, D. Himanshu

Category: Healthcare

Abstract:Objectives: Stress hyperglycemia, the acute and transient hyperglycemia has been studied in many critical illnesses like stroke and myocardial infarction. THRIVE score proved to be an impressive predictor of in-hospital mortality in previous studies but data on Indian population are lacking. This observational study was conducted to assess the different short term mortality predictors in acute stroke.
Materials & Methods: A total of 150 acute stroke patients presenting within 24 hours of onset, who had CT scan evidence and/or met minimum WHO criteria for diagnosis of stroke were included. Patients with TIA, recurrent stroke, secondary hyperglycemia, traumatic hematomas were excluded. Blood glucose and THRIVE score values were obtained on admission. Stroke severity assessed by NIHSS score, while mRS score was used for disability assessment.
Results: We divided our study cohort into 4 groups. A cut off blood glucose of 140mg/dl was set for defining hyperglycemia. Out of 71 patients in group C(non diabetics with stress hyperglycemia), 54 expired (76.1%). The burden of stress hyperglycemia was more in ischemic stroke(65.1%) as compared to hemorrhagic stroke (57.1%). In a multivariate model, where age, GCS, NIHSS score were kept as predictors of mortality, stress hyperglycemia had been found to be an independent predictor of in-hospital post stroke mortality. THRIVE score of 6 or above predicted mortality in majority of non survivors.
Conclusion: Stress hyperglycemia was found to be a significant poor prognostic determinant. While THRIVE score proves to be an impressive prognostic tool, its validation as independent mortality predictor in acute stroke needs further research.

Keywords: Stress hyperglycemia, Stroke, Admission hyperglycemia, Hyperglycemia stress, THRIVE score, Cerebrovascular accident

Full Text:

INTRODUCTION:

‘Stroke’, a leading cause of significant mortality and morbidity, got its name from the Greek word  “ apoplexia” meaning “being struck with a deadly blow”.[1,2] Stroke was the second largest cause of global death (5.5 million) after ischemic heart disease in 2016.[3] Overall mortality was higher in hemorrhagic stroke as compared to ischemic stroke cases. The outcome of stroke is influenced by various factors including severity, type of stroke, predisposing factors and related complications. Stroke has many risk factors- some are modifiable like hypertension, dyslipidemia, smoking, alcohol consumption, sedentary lifestyle and some are non-modifiable factors like age, sex and ethnicity. One of the potentially modifiable risk factors of stroke is stress hyperglycemia or admission hyperglycemia. Various studies showed the adverse effects of admission hyperglycemia on the short term outcome in acute stroke.[4] This acute hyperglycemia in stroke is not always due to type 2 diabetes mellitus but instead may be due to stress response mediated partly by the release of cortisol and norepinephrine.[5] Hyperglycemia can lead to poor outcome in acute stroke by different mechanisms- direct tissue damage mediated by lactate and intracellular acidosis in ischemic brain, increased free fatty acid pool interfering with vasodilation, cerebral vasculopathy induced by hyperglycemia [6].

German stroke study in 2004, predicted that mortality in ischemic stroke increases with i) NIHSS score>25 ii) higher age iii) fever>380c [7]. Weimer et al [8] in 2006 proposed a new prognostic model of hemorrhagic stroke termed Essen ICH score in which he utilized variables like i) Age, ii) NIHSS Score, iii) Level of consciousness. Stress hyperglycemia or transient admission hyperglycemia has been studied in many critical illnesses including myocardial infarction and stroke.[9] The independent prognostic role of stress hyperglycemia in acute stroke is yet to be deciphered. Totaled Health Risks in Vascular Events (THRIVE) score (totaled health risks in vascular events) calculated with age, NIHSS, and the presence of hypertension, diabetes mellitus, and atrial fibrillation proved to be a significant mortality predictor in acute ischemic stroke in previous studies [ 10 ] but sufficient data are lacking. Thus, we planned our study to assess the different prognostic variables including  stress hyperglycemia and THRIVE score and their impact on the outcome in acute stroke patients.

MATERIALS AND METHODS:

The present study was a prospective observational study conducted in the department of Medicine, King George’s Medical University, Lucknow in the Indian state of Uttar Pradesh. The study protocol was approved by the Institutional Ethical committee, King George’s Medical University. A total of 150 consecutive acute stroke patients who presented to the outpatient department/emergency, within 24 hours of onset of deficit and who had CT scan evidence of stroke and/or who met minimum World Health Organisation criteria for the diagnosis of stroke(i.e. rapidly developing focal neurological deficit lasting 24 hours or more)  were enrolled after taking formal informed written consent from legal guardians. Patients who presented after 24 hours, who had Transient Ischemic Attacks(TIA), recurrent stroke, secondary hyperglycemia, traumatic hematomas, vascular malformations, aneurysms and coagulopathies were excluded from the study.

All participants were evaluated by detailed history (including history of diabetes, hypertension and any other comorbidities), clinical examination and severity assessment by NIHSS(National Institute of Health Stroke Scale)score[11] and GCS (Glasgow coma scale) score. Ischemic stroke and hemorrhagic stroke were defined by neurological examination and CT brain (normal CT brain scan or recent infarct or evidence of haemorrhage in the clinically relevant area on scan done within 72 hours of onset).

A baseline Electrocardiogram was obtained from all patients. Fresh blood samples at the time of admission were drawn for complete blood counts, blood glucose, Glycosylated haemoglobin(HbA1c), C reactive protein (CRP) and lipid profile(Total cholesterol, LDL-cholesterol, HDL cholesterol).All blood investigations were carried out at the pathology and biochemistry laboratories of King George’s Medical University using standard protocols.

Serial random venous blood glucose values were measured on day of admission and at 12 hours,48 hours, 72 hours post admission and on day of discharge. A meticulous drug history was taken (thiazides, betablockers, glucocorticoids, OCPs, cyclosporine) and patients taking such drugs were excluded from the study. Adequate care was taken not to take samples for RBS from sites with intravenous lines. Hyperglycemia in our study was defined as blood glucose > 140 mg/dl or 7.8 mmol/L.

We divided our study cohort on the basis of diabetic history or use of medications for diabetes, HbA1c and admission glucose values into four different groups-

1.GROUP A- DIABETICS WITH  HYPERGLYCEMIA ON ADMISSION

Patients with a history of diabetes or use of medications or HbA1c>6.5% and admission glucose > 140 mg/dl

2. GROUP B- DIABETICS WITHOUT HYPERGLYCEMIA ON ADMISSION-

Patients with a history of diabetes or use of medications or HbA1c>6.5% and admission glucose <=140 mg/dl

3. GROUP C- NON DIABETICS WITH HYPERGLYCEMIA ON ADMISSION-

Patients without a history of diabetes or use of medications and HbA1c < 6.5% and admission glucose >140 mg/dl

4. GROUP D- NON DIABETICS WITHOUT HYPERGLYCEMIA ON ADMISSION-

Patients without a history of diabetes or use of medications and HbA1c <6.5% and admission glucose <=140mg/dl

All patients were followed up during hospital stay for recovery (using regular GCS assessment), complications like Sepsis, co-morbidities, length of hospital stay and outcome that included mortality and discharge. Totaled Health Risks in Vascular Events (THRIVE) score was calculated for all patients participating in the study using parameters of age, NIHSS score and chronic disease scale that includes history of diabetes, hypertension, atrial fibrillation.Functional recovery on discharge was determined by Modified Rankin Scale(mRS).

Statistical Analysis: The statistical analysis was done using SPSS version 21.0 statistical analysis software. The values were represented in Number (%) and Mean + Standard Deviation. To test the significance of two means, student’s ‘t’ test was used. Categorical variables were analysed with Chi square test. Cut-off levels of blood glucose values that predicted death was determined by ROC curve analysis. At multivariate level, variables associated with mortality and poor functional outcome were determined using logistic regression analysis. Multivariate modeling included variables with p < 0.05 at uni-variate level. A p-value of <0.05 was considered significant.

RESULTS :

A total of 150 patients were analysed in our study. Age of patients ranged from 18 to 98 years. Mean age of patients was 66.93±16.00 years. Majority of patients were males (70%). Male to female ratio was 2.33. Almost half (n=74; 49.3%) were hemorrhagic stroke cases whereas remaining (n=76; 50.7%) were ischemic stroke. Among the hemorrhagic stroke, combined basal ganglia and ventricles constituted the commonest site of involvement (75.7%) whereas middle cerebral artery(93.4%) was the commonest site involved in ischemic stroke cases. 

Mean admission GCS and NIHSS were 8.03±2.64 and 26.09±6.66 respectively. Mean systolic and diastolic blood pressure values were 164.57±15.04 and 90.95±9.98 mmHg respectively. Mean admission blood glucose level was 178.53±70.45 mg/dl. Mean serum cholesterol, HDL, LDL and triglyceride levels were 141.54±45.56, 40.78±3.24, 86.14±14.18 and 138.46±24.57 mg/dl respectively which were not significant statistically. A total of 59 (39.4%) cases were discharged, however, a total of 91 (60.7%) expired. Thus, in-hospital mortality rate was 60.7%.

Mean RBS levels at baseline, 12 hrs, 48 hrs, 72 hrs and at discharge were 178.53±70.45, 145.69±44.30, 140.91±36.79, 132.56±32.70 and 117.76±15.26 mg/dl respectively. Proportion of cases with hyperglycemia as per baseline, 12 hrs, 48 hrs, 72 hrs and at discharge were 77.3%, 30.7%, 36.5%, 32.1% and 6.9% respectively.

The area under curve values for overall study population, diabetics and non-diabetics were 0.698, 0.691 and 0.715 respectively, thus indicating an average diagnostic efficacy of baseline random blood sugar levels. For entire study population and non-diabetics, same cut-off value (>156.45 mg/dl or 8.68 mmol/L) was derived which was 68.1% sensitive and 64.4% specific for entire population and 68.9% sensitive and 64.7% specific for non-diabetics. For diabetics, the derived cut-off value was slightly higher at >157 mg/dl or 8.71 mmol/L and was projected to have 66.7% sensitivity and 64% specificity.

Mortality rate was maximum among non-diabetics with hyperglycemia at baseline(stress hyperglycemics) (76.1%)(Group C) followed by diabetics with hyperglycemia at baseline (58.7%)(Group A), diabetics without hyperglycemia at baseline (33.3%)(Group B) and was minimum among non-diabetics without hyperglycemia at baseline (29.2%)(Group D). Statistically, this intergroup difference was significant (p<0.001).

Table 5 shows that the mean NIHSS score in group A, group B, group C and group D were 26.28 + 6.41,22.22 + 6.18,27.34 + 7.15 and 23.46+ 4.53 respectively  Mean Baseline RBS values in different groups were respectively 207.29+94.26,123.67+6.87,187.09+50.41 and 118.65+14.83 respectively. Mean THRIVE score among different groups were 6.33+1.45,5.89+1.54,5.25+1.37 and 5+1.44 in groups A,B,C and D respectively. All of these three parameters show statistically significant intergroup differences ( p<0.05) with baseline RBS showing maximum significance(p<0.001).This also shows that patients with stress hyperglycemia have maximum stroke severity as compared to other groups.

Patients having stress hyperglycemia with THRIVE score >6 had a significantly higher mortality rate (88%) as compared to others (55.2%) (p=0.002).

Proportion of those with mRS>4(poor functional recovery) was maximum among diabetics with hyperglycemia at baseline (47.4%)(Group A) followed by non-diabetics with hyperglycemia at baseline (31.3%)(stress hyperglycemics)(Group C), non-diabetics without hyperglycemia (17.6%)(Group D) and diabetics without hyperglycemia at baseline(Group B)(16.7%). However, these differences were not significant statistically (p=0.224).

In a multivariate model where age, GCS, NIHSS, baseline RBS, THRIVE score and stress hyperglycemia were kept as predictors of mortality, only stress hyperglycemia and baseline RBS levels were found to be significant independent predictors of in-hospital mortality.

DISCUSSION:

Cerebro-vascular accident or stroke is a major debilitating neurological disease contributing for an ever increasing burden of global mortality and morbidity. Diabetes and hyperglycemia are established risk factors for ischemic stroke. [12-15] While there are a number of studies based on ischemic stroke that showed worse outcomes with hyperglycemia [16], few others have shown that hyperglycemia can be protective in small vessel disease.[17]

A strong association is seen between hyperglycemia and increased mortality and morbidity, irrespective of the diabetes status in multiple cohorts [18-24] while contrasting reports are seen in some others. [25-26] Literature shows two meta-analysis which concluded that high blood glucose values increase both short term and long term mortality in hemorrhagic stroke. [27,28] However subarachnoid hemorrhage cases had also been included in these studies. There are many factors through which hyperglycemia could increase cerebral damage in ischemic stroke.[29] A high blood glucose on admission impaired recanalisation in patients with acute ischemic stroke. When brain is exposed to excessive levels of glucose, blood brain barrier gets disrupted and events like anaerobic glycolysis, lactate accumulation, acidosis, generation of free radicals, excitatory neurotransmitters release and calcium influx into the cell ensue. Poorly controlled hyperglycemia interferes with perfusion to the brain, tissue oxygenation and raises intracranial pressure thereby resulting in neuronal death. These mechanisms are responsible for hyperglycemia induced damage in hemorrhagic stroke.

There is no clear cut off values of admission glucose which can predict outcome in acute stroke patients. We tried to find a definite cut off for admission glucose in our study that could signify poor prognosis in stroke patients by using ROC analysis.[Fig 1]  For entire study population and non diabetics, same cut off value (> 156.45mg/dl or 8.68 mmol/L) was derived which was 68.1% sensitive and 64.4% specific for the entire population[Fig 1 a] and 68.9% sensitive and 64.7% specific for non-diabetics.[Fig 1c]  For diabetics, the derived cut off value was slightly higher at > 157mg/dl or 8.71mmol/L with 66.7% sensitivity and 64% specificity.[Fig 1b] The almost same cut off values for both diabetics and non diabetics could be due to the well controlled diabetics being included in our cohort.

The in-hospital mortality in our study was 60.7% which is quite higher than previous studies. [30-32]This can be attributed to the greater stroke severity (mean NIHSS score 26.09+ 6.66), inability to perform thrombolysis or surgical interventions and lack of a well equipped stroke unit in our hospital.

Group C or the stress hyperglycemia group had the maximum mortality(76.1%) followed by Group A (58.7%).[Table 4] Group C also had a higher mean NIHSS (27.34+ 7.15) which signifies greater stroke severity among them.[Table 5] Admission hyperglycemia is related to greater stroke severity which is evident in previous studies. [33]

Most of the available studies related to stress hyperglycemia are on ischemic stroke patients [34-40] with limited data on hemorrhagic stroke. [41,42] Our study cohort consisted of both ischemic and hemorrhagic stroke cases. Stress hyperglycemia proved to be a poor prognostic marker for both types but the effect on the outcome of ischemic stroke is more deleterious than on hemorrhagic type (78% vs 69.6% mortality).[Table 6]

Totaled Health Risks in Vascular Events (THRIVE) score (totaled health risks in vascular events) is calculated with age, NIHSS, and the presence of hypertension, diabetes mellitus, and atrial fibrillation and was validated to predicting clinical outcome and hemorrhagic transformation in patients receiving tissue Plasminogen Activator, showed to be a simple score to help clinicians to estimate outcome and death after acute ischemic Stroke. [43]The performance of THRIVE score in predicting short term mortality had been established in a Brazilian study [9]. In our study, a THRIVE score of 6 or above was present in majority of non survivors (69.6%) (p=0.018). A greater proportion of non survivors (88%) with a high THRIVE score (> 6)   had a stress response (stress hyperglycemia) (p=0.002).

Our study failed to delineate the impact of stress hyperglycemia on functional recovery after stroke. [Table 9]  A poor functional recovery (mRS> 4) was more evident among diabetics with admission hyperglycemia (Group A) as compared to stress hyperglycemics ( Group C) which is in contrast to the previous studies. [32,34] This discrepancy may be due to a shorter follow up period of patients in our study.

The Glycemia in Acute Stroke (GLIAS) study was a large, multicentre cohort study of 476 patients. The study showed that a capillary glucose value >155 mg/dL(8.5 mmol/L) at any time within the first 48 hours, independent of age, stroke severity, or infarct volume, is associated with a higher mortality risk in ischemic stroke patients. [44]

 In univariate analysis, in our study, except for age, on admission GCS, NIHSS score, stress hyperglycemia and THRIVE score, none of the other clinical or laboratory parameters showed a significant association with outcome (p <0.05). Sepsis showed a non significant association with mortality (p=0.34), thus excluded from multivariate model.

In multivariate analysis, our study demonstrates stress hyperglycemia to be an independent predictor of mortality. [Table 10] THRIVE score failed to show significance in multivariate model.

However, our study had a few limitations. Being a tertiary care centre, patients often got their pre-referral treatment like dextrose containing drips at primary centres that might have affected the admission glucose values in our study. Post discharge glycemic status and its relation with mortality had not been taken into account which forms another major limitation. Besides, limited sample size and inability to evaluate hematoma/infarct volume which has independent prognostic effect on outcome were the drawbacks of our study. The impact of glucose lowering on the outcome of stroke couldn’t be determined.

CONCLUSION:

In this observational study, stress hyperglycemia was found to be an independent predictor of short term mortality in acute stroke patients when adjusted with age, GCS and NIHSS score. A  baseline blood glucose more than 156.45mg/dl or 8.68 mmol/L was found to be significantly associated with mortality. Though THRIVE score was not found to be an independent mortality predictor, a score of 6 or above could predict mortality in majority of non survivors. In conclusion, our study raises two vital queries –

 1- Do we need to treat stress hyperglycemia in acute stroke patients?

2- Do we need to include acute glucose in THRIVE prognostic model to better predict post stroke outcome?  

Large multicentric studies need to be conducted to address the above mentioned issues.

ACKNOWLEDGEMENTS: The authors would like to acknowledge the technical support provided by the Department of Neurology and Department of  Pathology, King George’s Medical University, Lucknow, India. 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.

CONFLICTS OF INTEREST: None stated

FUNDING: No funding source

ETHICAL APPROVAL: Ethical clearance for the study was obtained from Institutional ethical committee, King George’s Medical University.

INFORMED CONSENT: Written informed consent was obtained from legal guardians of all study patients.

ABBREVIATIONS:

GCS- Glasgow Coma Scale

NIHSS- National Institutes of Health Stroke Scale

THRIVE score- Totaled Health Risks in Vascular Events

WHO- World Health Organisation

mRS- Modified Rankin Score

References:

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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.
A study by Shafaque M. et al. entitled \"A Case-Control Study Performed in Karachi on Inflammatory Markers by Ciprofloxacin and CoAmoxicillin in Patients with Chronic Suppurative Otitis Media\" is awarded Best Article of Vol 14 issue 17
A study by Ali Nawaz et al. entitled \"A Comparative Study of Tubeless versus Standard Percutaneous Nephrolithotomy (PCNL) \? A Randomized Controlled Study\" is awarded Best Article for Vol 14 issue 16.
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
A Study by Monica K. entitled "Risk Predictors for Lymphoma Development in Sjogren Syndrome - A Systematic Review" is awarded Best Article for Vol 14 issue 13
A Study by Mokhtar M Sh et al. entitled "Prevalence of Hospital Mortality of Critically Ill Elderly Patients" is awarded Best Article for Vol 14 issue 12
A Study by Vidya S. Bhat et al. entitled "Effect of an Indigenous Cleanser on the Microbial Biofilm on Acrylic Denture Base - A Pilot Study" is awarded Best Article for Vol 14 issue 11
A Study by Pandya S. et al. entitled "Acute and 28-Day Repeated Dose Subacute Toxicological Evaluation of Coroprotect Tablet in Rodents" is awarded Best Article for Vol 14 issue 10
A Study by Muhammad Zaki et al. entitled "Effect of Hemoglobin Level on the Severity of Acute Bronchiolitis in Children: A Case-Control Study" is awarded Best Article for Vol 14 issue 09
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
A Study by Prabhu A et al. entitled "Awareness of Common Eye Conditions among the ASHA (Accredited Social Health Activist) Workers in the Rural Communities of Udupi District- A Pilot Study" is awarded Best Article for Vol 14 issue 07
A Study by Divya MP et al. entitled "Non-Echoplanar Diffusion-Weighted Imaging and 3D Fiesta Magnetic Resonance Imaging Sequences with High Resolution Computed Tomography Temporal Bone in Assessment and Predicting the Outcome of Chronic Suppurative Otitis Media with Cholesteatoma" is awarded Best Article for Vol 14 issue 06
A Study by Zahoor Illahi Soomro et al. entitled "Functional Outcomes of Fracture Distal Radius after Fixation with Two Different Plates: A Retrospective Comparative Study" is awarded Best Article for Vol 14 issue 05
A Study by Ajai KG & Athira KN entitled "Patients’ Gratification Towards Service Delivery Among Government Hospitals with Particular Orientation Towards Primary Health Centres" is awarded Best Article for Vol 14 issue 04
A Study by Mbungu Mulaila AP et al. entitled "Ovarian Pregnancy in Kindu City, D.R. Congo - A Case Report" is awarded Best Article for Vol 14 issue 03
A Study by Maryam MJ et al. entitled "Evaluation Serum Chemerin and Visfatin Levels with Rheumatoid Arthritis: Possible Diagnostic Biomarkers" is awarded Best Article for Vol 14 issue 02
A Study by Shanthan KR et al. entitled "Comparison of Ultrasound Guided Versus Nerve Stimulator Guided Technique of Supraclavicular Brachial Plexus Block in Patients Undergoing Upper Limb Surgeries" is awarded Best Article for Vol 14 issue 01
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
A Study by Kholis Ernawati et al. entitled "The Utilization of Mobile-Based Information Technology in the Management of Dengue Fever in the Community Year 2019-2020: Systematic Review" is awarded Best Article for Vol 13 issue 18
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
A Study by Chandran Anand et al. entitled "A Prospective Study on Assessment of Quality of Life of Patients Receiving Sorafenib for Hepatocellular Carcinoma" is awarded Best article for Vol 13 issue 15
A Study by Rosa PS et al. entitled "Emotional State Due to the Covid – 19 Pandemic in People Residing in a Vulnerable Area in North Lima" is awarded Best Article for Vol 13 issue 14
A Study by Suvarna Sunder J et al. entitled "Endodontic Revascularization of Necrotic Permanent Anterior Tooth with Platelet Rich Fibrin, Platelet Rich Plasma, and Blood Clot - A Comparative Study" is awarded Best Article for Vol 13 issue 13
A Study by Mona Isam Eldin Osman et al. entitled "Psychological Impact and Risk Factors of Sexual Abuse on Sudanese Children in Khartoum State" is awarded Best Article for Vol 13 issue 12
A Study by Khaw Ming Sheng & Sathiapriya Ramiah entitled "Web Based Suicide Prevention Application for Patients Suffering from Depression" is awarded Best Article for Vol 13 issue 11
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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