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IJCRR - 2nd Wave of COVID-19: Role of Social Awareness, Health and Technology Sector, June, 2021

Pages: 210-214

Date of Publication: 11-Jun-2021


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Drug Utilisation Study among COVID-19 Inpatients in a Tertiary Care Hospital in Eastern India

Author: Manjhi PK, Singh SK, Kumar R, Singh S, Priya A, Nishi

Category: Healthcare

Abstract:Introduction: Coronavirus disease-2019 (COVID-19) is a global pandemic without any specific treatment to date. Drug utilisation plays a vital role in helping the health care system to understand the pattern of drug use. Aim: To assess the prescribing trends among COVID-19 patients admitted to the hospital. Methodology: This was a retrospective cohort study conducted at a tertiary hospital dedicated to COVID-19 patients. Patients admitted in AIIMS, Patna from March 2020 to October 2020 were analyzed for WHO core prescribing indicators and was compared with the standard WHO values. Results: The median value of drugs prescribed was found to be 7 (IQR-6-8). The most common drugs prescribed for COVID-19 were Azithromycin (25.95%), hydroxychloroquine (23.88%) followed by paracetamol (20.17%) and Heparin (16.35%). The percentage of drugs prescribed by generic name was 77.72%. The average number of drugs from NLEM was 92.56%. Drugs were classified based on the Anatomical Therapeutic and Chemical Classification (ATC) and the majority of the drugs belonged to the J category which is the anti-infective group of drugs. The defined daily dose (DDD) /100 bed-days of azithromycin and cefixime was 5.2 and 0.092, respectively. Conclusion: Polypharmacy being the common finding, the concept of generic prescribing was practised well. There was a lesser number of prescriptions containing drugs from the National List of Essential Medicines, and the number of prescriptions containing antibiotics and injections was following criteria. The WHO prescribing criteria were met with moderate adherence.

Keywords: Drug utilisation, COVID-19, WHO prescribing criteria, Anatomical Therapeutic Chemical Classification (ATC), Defined Daily Dose (DDD), Polypharmacy

Full Text:

Introduction:

SARS-CoV-2 coronavirus causing Coronavirus disease 2019 originated in Wuhan, China in December 2019 and has spread rapidly across the world due to its high transmissibility and pathogenicity.1 It was shortly declared as a Public Health Emergency of International Concern and On March 11, a global pandemic was declared.2 Since then many drugs have been tried to treat COVID-19 infection but the effort has mostly been focused on repurposing existing medicines. The drugs that may be reused are from different pharmacological categories i.e. antimalarial, anthelmintic, anti-protozoal, anti-HIVs, anti-influenza, antineoplastics, neutralizing antibodies, immunoglobulins, and interferons.3 These drugs have been used as a single agent or in combination, unfortunately, no medicine has yet been officially approved to treat COVID-19. The treatment guidelines for COVID-19 vary from one country to another. However, the treatment protocols across the countries are almost similar and vary very slightly and include hydroxychloroquine, chloroquine phosphate, Remedesivir, azithromycin, tocilizumab and lopinavir/ritonavir.4 In India COVID-19 treatment guideline has been changed several times based on the latest research data. Indian Council of Medical Research (ICMR), New Delhi recommended hydroxychloroquine for prophylactic purposes in asymptomatic healthcare workers and household contacts of laboratory-confirmed patients.5 The Government of India, Ministry of Health & Family Welfare, Directorate General of Health Services (Emergency Medical Relief (EMR) Division), recommended lopinavir/ritonavir after proper informed expressed consent from the patient.6 The Government of India, Ministry of Health & Family Welfare, Directorate General of Health Services (Emergency Medical Relief (EMR) Division), recommended HCQ for mild to moderate case, low molecular weight heparin and steroid for moderate to severe case of COVID-19.7 Spanish Society of Hospital Pharmacy recommended lopinavir/ritonavir, Remdesivir, hydroxychloroquine, chloroquine, darunavir/cobicistat, tocilizumab interferon and alfa-2B,beta-1B.8,9 US FDA has not yet approved any drug for COVID 19 although some information regarding the drugs recommended for the treatment has been provided by the Centers for Disease Control and Prevention and includes Remdesivir, chloroquine, hydroxychloroquine, and lopinavir/ritonavir.10 The drugs like Remdesivir, favipiravir, chloroquine phosphate, plasma, and traditional Chinese medicine was recommended by the National Health Commission of the People's Republic of China.11 At present there is the limited number of study which summarizes the drug Utilisation in corona infected patients in a tertiary care hospital in India. Drug utilisation focus on the factors related to the prescribing, dispensing, administering, and taking of medication, and the related events including medical and non-medical determinants of drug utilisation, the effects of drug utilisation, as well as how drug utilisation relates to the beneficial or adverse effects of drug use.12,13  Therefore this study has been designed to assess the prescribing trends among COVID-19 patients admitted to a tertiary care hospital in India. This study will be helpful to educate the prescribers, adherence towards rational drug therapy for safety and benefit to the patient.

Materials and methods:

This retrospective observational study was carried out at All India Institute of Medical Science (AIIMS), Patna, (Bihar) India. COVID-19 patients, admitted to AIIMS Patna from March 2020 to October 2020 were included in the study. Medical Records of (n = 300) COVID-19 patients from the Medical Record Department (MRD) were evaluated for 3 months. Data were recorded on a standardized format in which information on drug utilisation among COVID-19 patients which include patient’s demographic details (age, sex, duration of hospitalisation) and details of prescribed drugs (name, dose, therapeutic class, dosage form, route of administration, dosing frequency, etc.,) was retrieved from in-patient case files. Details of standard intravenous fluids, oxygen, vaccines and blood transfusion were not recorded. The prescription pattern was analysed using WHO’s core prescribing indicators. Drugs are divided based on pharmacological action on the organ or system and their therapeutic and chemical properties in the anatomical therapeutic chemical (ATC) classification.14The World Health Organization (WHO) Collaborating Centre for Drug Statistics Methodology defines the defined daily dose (DDD) as a statistical measure of drug consumption. For grouping related drugs, it is defined in conjunction with the ATC Code drug classification system. The DDD allows for drug usage comparisons between different drugs in the same group or between different health care environments which were calculated by the following formula.15

DDD/ 100 bed -days = 

Drug consumption in mg x 100

DDD (mg) x no. of days in study period x total no. of beds x occupancy index

The total number of beds used was 300 and the average occupancy index was 0.85. The occupancy index for every month was calculated by the Medical Records department. The occupancy index is the average monthly occupancy index for the three months of our study period.

Statistical analysis: Data were captured on Microsoft excel. The results were expressed as actual numbers, means, median (IQR) frequency (percentages) using SPSS software version 16.0., and were presented using tables.

Results:

Three hundred medical records of patients with confirmed COVID-19 patients were evaluated.  The demographic and clinical characteristics of the patients are shown in Table 1. Of the total study population, 71.33% were male. A median number of seven medications (IQR, 6–8) were administered for the patients. Diabetes (21%) and hypertension (21%) was the most common comorbidity followed by hypothyroidism (14.28%) and hypercholesterolemia (8.4 %).

The analysis of drug utilisation using WHO core prescribing indicators revealed that the percentage of encounters with antibacterials and injectables was 15.63% and 11.82%, respectively. The percentage of drugs prescribed with a generic name and from the Essential Drug List of India was 77.72% and 92.56%, respectively (Table 2).

 Looking at the individual drugs the most commonly prescribed drugs for COVID-19 patients include azithromycin (25.95%) hydroxychloroquine (23.88%), followed by paracetamol (20.17 %) and heparin (16.35%) from antimicrobial, analgesics, anti-inflammatory and an anticoagulant class of drugs, respectively.[Table 3]

The World Health Organization (WHO) defines polypharmacy as “the administration of many drugs at the same time or the administration of an excessive number of drugs”. Polypharmacy may be defined as the administration of five or more than five drugs simultaneously which is evident in our study. [Table 4]

Table 5 shows the Defined daily doses (DDD) by anatomical therapeutic chemical (ATC) classification codes of various drugs utilized among COVID-19 inpatients.

Discussion:

Drug Utilisation study is an important tool for ensuring quality in hospital drug use. The WHO core indicators of prescribing practice assess healthcare providers' performance in key dimensions related to drug safety. As a result, the purpose of this study was to examine the prescribing indicator that will aid in the promotion of rational drug use to improve drug safety.

The average number of drugs per encounter in our study was 6.97, which was higher than the national average.  WHO recommended range is 1.6-1.8.16 Our finding was higher than that of Hazra et al. (3.2)17 some international studies, such as Wang et al. (3.52),18  Bimo et al. (3.8)19, and other Indian studies, such as Rehan et al. (2.4)20 Tripathy et al.(2.9).21

The number of drugs prescribed in each encounter ranged from two to ten, with 27.33 % of encounters prescribing eight or more drugs, indicating a polypharmacy trend (Table 4). This was in line with Tripathy et al findings (30%).21 Polypharmacy has a variety of consequences, including adverse drug reactions, drug-drug interactions, therapeutic failure, and toxicity, reduces patient compliance, unnecessary drug costs, and the risk of bacterial resistance emergence when antibiotics from different classes are prescribed to the same patient without reason.

In our study, the percentage of drugs prescribed by generic names was 77.72%, which is less when compared to the standard WHO ideal value of 100%. It was higher than the findings of Chandelkar and Rataboli's study (0.05%)22, Rehan et al. (1.5%)20, Tripathy et al. (68 %),21  Hazra et al. (46.2 ),17 and other international studies.23,24

The analysis of two common expensive modes of drug administration such as antibiotics and injections showed that the percentage of encounters with antibiotics prescribed was 15.63%, which is less than the standard range of 20-26.8 % of the WHO prescribed values. The finding of other studies conducted in India such as Hazra et al. (72.8%),17 and Tripathy et al. (47.75 %) respectively.21 Lower rates of antibiotic prescribing in our study due to the viral origin of COVID-19.

The percentage of encounters with injections in our study was 11.82% which was lesser than the standard range of WHO ideal value (13.4-24.1%). It was higher to the findings from Tripathy et al. (8%)21 but very low compared to another region, South Ethiopia (38.1%)23 and Uganda (48 %).25

The percentage of drugs prescribed by the NLEM in our study was 92.56%, which was lower when compared to the ideal standard value of 100%. This finding was much more to findings from studies of other parts of India such as Hazra et al. (45.71%).17 The percentage of prescribing drugs from the essential drug list is lower in India17 compared to other countries such as Ethiopia (99%), South Ethiopia (99.6%),23 and Nepal (88%).19 This difference may be due to the lack of awareness of the essential drug list.  Between the mean of the estimated parameters, demographic data, it is involved in all of this, is similar to the findings in other studies.26 Compared to studies from Dubai where the patient name was missing in 2.9%, age in 9.7%, and sex in 12%.27 Lack of demographic indicators will lead to the source of serious medication error such as dispensing of medication to the wrong patients. The diagnosis was mentioned in 100% of prescriptions which was slightly more than other study results Shipra et al. (64.66%).26 The doses of drugs were mentioned for 100% of the drugs which was similar to other study results such as Shipra et al. (100%).26 Dosage form was mentioned in 100% compared to other study results Shipra et al. (98.66%).26Duration of treatment was mentioned in 100% compared to 92.66% in Shipra et al.26 The DDD per 100 bed-days ranges from 23.96 to 0.03. Vitamin C was found to be the most commonly prescribed drug with DDD per 100 bed- days of 23.96 followed by antimicrobials 5.37.  Among the antimicrobials, the defined daily dose (DDD) /100 bed-days of azithromycin and cefixime was 5.2 and 0.092, respectively.  Our study reports the highest use of vitamin C. which plays a very important role as an immune modulator28,29 and since this study was performed during the COVID-19 pandemic where vitamin C was used very widely and this could be the possible reason behind the highest use. The DDD per 100 bed-days of azithromycin, cefixime and ceftriaxone, levofloxacin was found to be much lesser than other studies.30

This study has certain limitations as it is retrospective a time-bound study with a small sample size and among COVID- 19 patients. It was not possible to assess the rationality and quality of prescriptions. However, it helps to create a drug Utilisation database in a tertiary care teaching hospital of a developing country.

Conclusion: The WHO core prescribing indicators were met with moderate adherence. With the prevalence of polypharmacy, the concept of generic prescribing has been practised well. The prescription of NLEM drugs, antibiotics, and injections was within normal limits. Drug utilisation among covid-19 as well complied with AIIMS-Patna covid management protocol.

Acknowledgement: We thank all corona warriors of AIIMS Patna working at the front line against COVID-19. We acknowledge the medical record department staff of the hospital for cooperation in providing medical records.

Ethical Approval and informed consent: The study was approved by the Institutional Ethics Committee, AIIMS Patna (Ref. No. AIIMS/Pat/IEC/2020/647 Dated 25/01/2021). Waiver of informed consent was granted as patient details were anonymized and only medical records of hospitalized COVID-19 patients were analyzed.

Financial support of the study: Nil

Conflict of Interest: None declared

Author’s contribution: Manjhi PK analyzed data and wrote the manuscript. Singh SK wrote the introduction and Kumar R analyzed data. Priya A. and Nishi collected data from Medical Record Department. All authors read this manuscript.

References:

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  2. Sohrabi C, Alsafi Z, O'Neill N., World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19) Int J Surg. 2020;76:71-76.

  3. Rameshrad M, Ghafoori M, Mohammadpour AH, Nayeri MJD, Hosseinzadeh H., A comprehensive review on drug repositioning against coronavirus disease 2019 (COVID19). Naunyn Schmiedebergs Arch Pharmacol. 2020;393 (7):1137-1152.

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  5. National Taskforce for COVID-19 Advisory on the use of hydroxy-chloroquine as prophylaxis for SARS-CoV-2 infection 2020. Available from: https://www.mohfw.gov.in/pdf/AdvisoryontheuseofHydroxychloroquinasprophylaxisforSARSCoV2infection.pdf

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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
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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
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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
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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
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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
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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
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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
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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
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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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