Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
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Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
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On Sep 2018

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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help ones reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journalsNo manuscriptsNo authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Important Notice

Original article / research
Year : 2007 | Month : August | Volume : 1 | Issue : 4 | Page : 248 - 255

Prescribing Pattern in Diabetic Outpatients in a Tertiary Care Teaching Hospital in Nepal


*Department of Hospital and Clinical Pharmacy, Manipal Teaching Hospital, Pokhara, Nepal. **Department of Pharmacology,Manipal College of Medical Sciences, Pokhara, Nepal.

Correspondence Address :
Dinesh K Upadhyay, M.Pharm, Assistant Professor. Department of Hospital and Clinical Pharmacy/ Pharmacology, Manipal Teaching Hospital/Manipal College of Medical Sciences, Pokhara, Nepal. Tel.: 061-526420/526416 (Extn 221);


Background: Diabetes is a chronic disease associated with significant morbidity and mortality. Diabetics are at a higher risk of polypharmacy and more vulnerable to irrational prescription. Data regarding drug use pattern in diabetes is lacking in South Asian countries.
Objectives: The present study was conducted with the objectives of collecting the demographic details of diabetes patients, studying the pattern of drug prescribing among diabetic outpatients, calculating the mean prescription cost for the diabetes patients and analysing the prescriptions according to prescribing indicators.
Methods: A cross-sectional study was carried out at the Out-patient Pharmacy (OPP), Manipal Teaching Hospital, Pokhara, Nepal, from 22nd August to 7th December 2006. All the diabetes patients who visited the OPP during the study period were enrolled after getting verbal consent and interviewed by the researchers, based on the study objectives. The details were entered in the structured patient profile form, and the filled forms were analysed.
Results: Altogether 182 patients, 103 males (56.59%) and 79 females (43.41%), were enrolled. Among these, 69 (37.91%) were in the age group 51–60 years, 128 (70.33%) had a diabetic history of less than 5 years and 136 (74.72%) had at least one concurrent illness. Two, three and four drugs were prescribed in 39 (21.43%), 35 (19.23%) and 40 (21.98%) patients, respectively. Altogether, 685 drugs were prescribed with an average of 3.76 drugs per prescription. Antidiabetics were accounted for 314 (45.84%) of the total drugs. Among the various antidiabetics, biguanides were accounted for 161 (51.27%) of the total antidiabetic medications. Among the study patients, 28 (15.38%) had an encounter with an injection prescribed and 16 (2.34%) of the total drugs were fixed-dose combinations and 0.88% (n = 6) of the drugs were antibiotics. The duration of prescription of medicines ranges from 29 to 35 days for 41.17% (n = 282) of the total drugs and 57 to 63 days for 44.23% (n = 303) drugs. Majority [650 (94.89%)] of the drugs were prescribed in oral dosage form. The average cost per prescription was NPR 1156.15 (US $16.17). Antidiabetic medications constituted 58.93% of the total cost. Among the antidiabetic medications insulin accounted for 41.07% of the total cost followed by biguanides (32.60%).
Conclusions: Insulin and biguanides were the most commonly prescribed antidiabetics. Our study was done for a short period of time, and the number of patients studied was low. Hence, similar studies covering large number of patients are needed to confirm our findings.


Antidiabetic medication, diabetes, Nepal, prescribing patterns

Diabetes is a chronic disease, affecting nearly 6% of the world population (1). It is associated with abnormal carbohydrate, protein and lipid metabolism (2). In Nepal, the incidence of diabetes and impaired fasting glycaemia was found to be 14.6% and 9.1%, respectively, in people aged 20 years, in urban and 2.5% and 1.3% in rural areas (3). The management of type-1 diabetes depends on insulin mainly, whereas the management of type-2 diabetes is mainly managed using oral hypoglycaemic agents (OHAs) (4). Diabetes, if uncontrolled, leads to several acute and chronic complications (5). The chronic complications of diabetes make it necessary to prescribe drugs for these patients life long. Moreover, a good number of diabetes patients suffer from cardiovascular disease such as hypertension, hyperlipidaemia and ischaemic heart disease (2). This further necessitates polypharmacy in these patients.

In Nepal, several problems in drug use patterns have been reported. This includes use of irrational combinations, excessive prescription of multivitamins, use of antibiotics in viral infections, etc. (6). Often, the chronically ill patients like the diabetic patients suffer from multiple diseases and hence are prescribed multiple drugs. Moreover, irrational prescribing can lead to an increase in the cost of drug therapy, which may lead to non-adherence. A study from the United States of America (USA) reported that about 1.3 million adults with disabilities did not take their medications as prescribed because of cost, and as a result, more than half reported health problems (7). In diabetes, the complications can be prevented only if the patient maintains strict glycaemic control (8),(9). Carrying out a drug utilisation study can provide valuable information to the researchers, policy makers and the drug and therapeutics committee members to determine the drug use pattern. During our literature review, we could not locate such a study from South Asia. Hence, the present study was carried out with the following objectives:

1. to study demographic details of diabetes patients;
2. to study the pattern of drug prescribing among diabetic outpatients;
3. to calculate the mean cost of the prescription; and
4. to analyse the prescriptions as per the International Network for Rational Use of Drugs/World Health Organisation (INRUD/WHO) indicators.

Material and Methods

Study type
Cross-sectional study.

Study site
Out-patient Pharmacy (OPP), Manipal Teaching Hospital, Pokhara, Nepal.

Study duration
The study was carried out from 22nd August to 7th December 2006.

Inclusion and exclusion criteria
All the diabetes patients who visited the OPP during the study period were enrolled in the study. In case if a diabetic patient has not taken medicines from our OPP, those patients were excluded.

Operational modality
Patients were enrolled in the study after getting a verbal informed consent. Patients were interviewed by the researchers based on the study objectives. The details were entered in the structured patient profile form.

Result analysis
The filled patient profile form was analysed for various parameters like age distribution and gender of patients, duration of diabetes, concurrent illness, family history of diabetes, number of drugs per prescription, average number of drugs prescribed, therapeutic category of drugs, class of antidiabetics, types of insulin preparations used, dosage form, duration of therapy and the prescribing indicators.


Altogether 182 patients were enrolled in the study.

Demography details
Males were 103 (56.59%) and females were 79 (43.41%). Among these patients, the greatest number were in the age group of 51–60 years [69 (37.91%)], followed by 61–70 years [40 (21.98%)], 41–50 years [31 (17.03%)], 31–40 years [13 (7.14%)], 21–30 years [3 (1.65%)], less than 10 years [1 (0.55%)] and more than 70 years [25 (13.74%)]. The mean +/- SD age of the patients was 56.9 +/- 12.55 years.

Duration of diabetes (n = 182)
Among the study population, 128 patients (70.33%) had a diabetic history of less than 5 years, followed by 6–10 years in 41 patients (22.53%), 11–15 years in six patients (3.30%), 16–20 years in six patients (3.30%) and more than 20 years in one patient (0.55%).

Coexisting illness
Among the 182 patients, 136 (74.72%) had at least one coexisting illness during the study period. There were total of 177 illnesses in these 136 patients. The detail regarding the coexisting illness of the study patients is shown in (Table/Fig 1).

Family history of diabetes
Among the study population, one (0.55%) had both the parents suffering from diabetes. Two (1.1%) patients had their father alone and three (1.65%) had their mother alone suffering from diabetes. The details regarding the family history of 163 (89.56%) patients were not available.

Number of drugs per prescription (n = 182)
Among the study patients, one, two, three, four, five and six drugs were prescribed in 12 (6.59%), 39 (21.43%), 35 (19.23%), 40 (21.98%), 26 (14.29%) and 17 (9.34%) patients, respectively. More than six drugs were prescribed in 13 (7.14%) patients. The average number of drugs per prescription was 3.76.

Therapeutic category of drugs prescribed
Altogether 685 drugs were prescribed in the study population. Antidiabetics were the commonest class of drugs accounting for 314 (45.84%) of the total drugs. The details regarding the therapeutic category of drugs prescribed are listed in (Table/Fig 2).

Class of antidiabetics
Among the various antidiabetics, biguanides were the common class of drugs accounting for 161 (51.27%) of the total antidiabetics, followed by sulfonylureas 111 (35.35%), insulin 25 (7.96%), thiazolidinediones 15 (4.78%), meglitinides and alpha glucosidase inhibitors 1 (0.32%).

Type of insulin prescribed (n = 25)
Among the various insulin preparations, Insulin (30/70) was prescribed in 24 (96%) patients and Insulin Human Mixtard in one (4%) patient.

Duration of drug therapy
Twenty-three (3.36 %) drugs were prescribed up to 7 days, 23 (3.36%) for 8–14 days, 23 (3.36%) for 15–21 days, 282 (41.17%) for 29–35 days, five (0.73%) for 43–49 days, 303 (44.23%) for 57–63 days and 26 (3.80%) for 85–91 days. The mean +/- SD duration of the drugs was 43.69 +/- 19.62 days.

Dosage form
Majority of the drugs were prescribed in oral dosage form [650(94.89%)] followed by parenteral [28 (4.09%)], inhalation [4(0.58%)] and topical [3(0.44%)] preparations.

Average cost of the prescription
The average cost per prescription was found to be NPR 1156.15 (US $16.17). The details regarding the cost of the prescriptions are listed in (Table/Fig 3).

Cost distribution among the antidiabetics
Antidiabetic medications constituted 58.93% of the total cost of medications. Insulin was the antidiabetic drug responsible for the highest percentage of the cost incurred on antidiabetics. The details regarding the cost distribution among the antidiabetic drugs is listed in (Table/Fig 4).

Prescribing indicators
The analysis as per the INRUD/WHO indica


Diabetes is a chronic disease requiring lifelong treatment. Although lifestyle modifications play an important role in diabetes management, drugs become unavoidable in many patients. This study analysed the prescription pattern in diabetic patients attending out-patient departments in a Nepalese hospital. The average number of drugs per prescription was found to be 3.76. Biguanides were the most commonly prescribed antidiabetics. Majority of the drugs were prescribed in oral dosage form. Antidiabetic medications accounted for more than half of the total prescription cost.

In this study, we found a higher incidence of diabetes among elderly patients, with a high incidence in the age group 51–60 years. The mean +/- SD age of patients in this study was 56.9 +/- 12.55 years. A study from Netherlands had reported an average age of 67 years (10). Another study from Spain reported an average age of 60.5 +/- 12.8 years (11). This study reported a lower age of patients as compared to other studies. In general, elderly patients are at greater risk of developing type-2 diabetes mellitus (DM). The duration of diabetes plays an important role in diabetes management. In patients with a long duration of diabetes, tight glycaemic control results in a lesser incidence of complications.

In the present study, nearly two-thirds of the patients had a diabetic history of less than 5 years. A study from Spain reported the mean duration of diabetes as 11.8  8.0 years (11). Patients with a long duration of diabetes are at a higher risk of developing complications. Among the various complications, cardiovascular complications pose a major threat. In this study, hypertension accounted for 70.62% of the total complications seen in the diabetes patients.

Once the patients are diagnosed to have cardiovascular complications, multiple drugs are required for their management. Polypharmacy is associated with a higher cost, increased risk of side effects, drug interactions and non-compliance (12),(13),(14). One should be especially aware of the drug interactions between antidiabetics and antihypertensive drugs. Drugs like beta blockers and ACE inhibitors can interact with antidiabetic drugs. Beta blockers are known to mask the symptoms of hypoglycaemia if taken with insulin (15). Similarly, ACE inhibitors are known to have a hypoglycaemic effect. In post-marketing studies, hypoglycaemia has been reported in patients taking Ramipril and concomitant hypoglycaemic agents or insulin (16). If prescribed simultaneously, the patients should be counselled regarding the possible risk of hypoglycaemia.

Depression was responsible for 6.21% of the concurrent complications in our patients. In general, diabetes patients are at a higher risk of developing depression. Studies suggest that diabetes doubles the risk of depression (17). These patients are more vulnerable to miss their medications, and the possibility of non-adherence is very high (18). Moreover, certain antidepressants such as tricyclic antidepressants (TCAs) are known to cause cardiovascular complications, and hence the doctor should be careful while prescribing antidepressants to these patients. According to one study, the use of higher dose of TCAs was associated with an increased risk of sudden cardiac death (19). In our study, antidepressants accounted for 1.75% of the total drug prescribed.

The average number of drugs per prescription was 3.76. In general, due to multiple diseases, diabetes patients are at a greater risk of polypharmacy. Previous studies from our hospital have identified lacunae in drug use pattern in the hospital (20),


The study was successful in studying the prescribing pattern of antidiabetics in a Nepalese teaching Hospital. The study found the incidence of polypharmacy in diabetes patients to be high. The prescription cost can be reduced by choosing cheaper brands, and the hospital DTC has a major role in improving the prescribing habits in diabetes patients, as well as in procuring economic brands for the hospital. There is also a huge scope for improving prescribing by generic name.


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Tables and Figures
[Table / Fig - 1] [Table / Fig - 2] [Table / Fig - 3] [Table / Fig - 4] [Table / Fig - 5]

JCDR is now Monthly and more widely Indexed .