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

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Dr Bhanu K Bhakhri

"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.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"

Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"

Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"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."

Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."

Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
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 one’s 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 journals–No manuscripts–No 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.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
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

Case report
Year : 2008 | Month : April | Volume : 2 | Issue : 2 | Page : 754 - 756

Life Threatening Lactic Acidosis Secondary To Metformin, In A Low Risk Patient


*Attending physician, **Consultant, pulmonary and ICU, ***Consultant Department of medicine, Hamad General Hospital. Doha-Qatar.

Correspondence Address :
Fahmi Yousef Khan, (MD., Senior specialist, Department of medicine, Hamad General Hospital,Tel 0974-4879228, 5275989, Fax 4392273, P.O.Box 3050, E-mail:, Doha-Qatar.


A 45-year-old lady was admitted to the intensive care unit (ICU) with a two day history of persistent nausea, vomiting, abdominal pain, and shortness of breath. Her medical history was remarkable for diabetes mellitus (DM) type II on Gliclazide 80 mg twice daily, and metformin 500 mg, three times daily. On examination, the patient was tachypnic, with cold extremities. Blood chemistry showed: random blood sugar levels of 20.6 mmol/L, and blood lactate concentration levels of 9.45 mmol/L, while urine and plasma tests were negative for ketone bodies. A provisional diagnosis of metformin-induced lactic acidosis was made. Intravenous calcium gluconate, soluble insulin, and bicarbonate were given initially, and urgent haemodialysis was performed. On the following days, the level of lactic acid and potassium returned to normal. The patient made a subsequent smooth recovery, and did not require further renal support.


Lactic acidosis, Metformin

Metformin is a useful therapeutic agent for obese type II diabetics, and those whose glycaemia cannot be controlled by sulphonylurea monotherapy. Type B (non-hypoxic) lactic acidosis is an uncommon but potentially fatal adverse effect of metformin. The reported frequency of lactic acidosis ranges between 0.03 and 0.06 per 1000 patient-years, [1-3] mostly in patients with predisposing factors such as chronic renal failure. We report a 45 year old lady who developed life threatening lactic acidosis secondary to metformin, in the absence of pre-existing chronic renal failure or other predisposing factors.

Case Report

A 45-year-old lady was admitted to the ICU with a two day history of persistent nausea, vomiting, abdominal pain, and shortness of breath. Her medical history was remarkable for DM type 2 on Gliclazide 80 mg twice daily, and metformin 500 mg, three times daily. On examination, the patient was conscious, tachypnic, with cold extremities. Blood Pressure was 100/50 mmHg, Pulse was 110/min, body temperature was 36.3ÂşC, and respiratory rate was 30/min. Chest, heart, abdomen, and nervous system examination were unremarkable.

Initial investigations showed: haemoglobin level of 14 g/dL, total leukocyte count of 9500/uL platelet count of 467000/uL, blood urea nitrogen levels of 16 mmol/L, creatinine levels of 155µmol/L, sodium levels of 140 mEq/L, potassium levels of 7.5 mEq/L, chloride levels of 109 meq/L, bicarbonate levels of 8 mEq/L, calcium levels of 2.4 mmol/L, random blood sugar levels of 20.6 mmol/L, and blood lactate concentration levels of 9.45 mmol/L. Plasma test for ketone bodies was negative. Liver function test showed: asparate aminotransferase levels of 30 IU/L, alanine amino-transferase levels of 27 IU/L, alkaline phosphatase levels of 70 IU/L, total bilirubin levels of 9 µmol/L, total protein levels of 7.4 g/dL, and albumin levels of 3.8 g/dL. Her coagulation profile was normal. Arterial blood gas analysis at room air showed: pH 6.9, PaO2 109 mm Hg, PaCO2 20 mm Hg, and HCO3- 7.2 mEq/L. Her fasting lipid profile showed; a total cholesterol level of 5.1 mmol/L; LDL cholesterol levels of 2.2 mmol/L; triglyceride levels of 3.2 mmol/L. Myoglobin and creatine kinase (CK) levels were normal. The urine was negative for myoglobin, haematuria, pyuria, and ketonuria. An ECG trace showed normal sinus rhythm with peaked T waves (see (Table/Fig 1)). A review of the patient's biochemical profile, three weeks before admission, revealed normal renal function.

Although metformin level was not measured, metformin and gliclazide were stopped, and the patient was treated as a metformin induced lactic acidosis case. Intravenous calcium gluconate, soluble insulin, and bicarbonate infusion were given initially, and urgent haemodialysis was performed. On the following days, the level of lactic acid and potassium returned to normal. The patient made a subsequent smooth recovery and did not require further renal support; accordingly she was discharged in good condition on subcutaneous insulin.


Metformin is widely used because it has certain advantages over other oral hypoglycaemic agents, namely it does not cause hypoglycaemia, weight gain, or hyperinsulinaemia(4).

Metformin's mechanism of action is thought to be by increasing glucose transport into glucose utilizing cells, and by decreasing hepatic gluconeogenisis. (4) Biguanide therapy decreases the activity of the enzyme pyruvate dehydrogenase and the transport of mitochondrial reducing agents, and thus enhances anaerobic metabolism(5). This shift to anaerobic metabolism is therefore not dependant on a lack of oxygen, and in the presence of reduced insulin, increases the production of precursors for the tricarboxylic acid cycle. (5) As inhibition of pyruvate dehydrogenase leads to a decreased ability to channel these precursors into aerobic metabolism, this causes increased metabolism of pyruvate to lactate and an increase in lactic acid production. Any renal impairment will result in a reduced clearance of lactic acid and metformin.

Ninety percent of metformin is excreted unchanged by the kidneys, and lactic acidosis typically occurs in patients with renal insufficiency. (2) Significant renal impairment (serum creatinine >160 µmol/L) is a contraindication to the use of metformin, and mild renal disease increases the risk of lactic acidosis. Metformin is also contraindicated in chronic hepatic disease because of the increased risk of metformin-associated lactic acidosis. Patients with diabetes, frequently have abnormal liver function tests secondary to fatty liver, which in itself is not a contraindication. Other risk factors for metformin-associated lactic acidosis include conditions associated with hypoxia (e.g. recent myocardial infarction, cardiac failure, pulmonary disease and surgery), alcoholism, sepsis, high dosage, increasing age, and dehydration. [6,7] A metformin dosage of 850 mg twice a day, or 500mg three times a day, usually gives good diabetic control. In situations predisposing to dehydration, such as fasting for surgery or contrast radiography, metformin should be ceased at least 48 hours prior to the procedure (or on admission for an emergency procedure), and not restarted until the patient has fully recovered and is eating and drinking normally. The glucose levels of patients in catabolic states, e.g. sepsis or in the post-operative period should be closely monitored, and a short-term insulin therapy should be strongly advised. Caution is needed when increasing the daily dosage beyond 1.7g, especially in the elderly, and those with mild renal disease. Our patient had no obvious risk factor, and had normal renal function three weeks before admission. The mild renal impairment at the time of presentation was due to dehydration caused by severe vomiting.

One study (8) has shown that there is no evidence from prospective comparative trials or from observational cohort studies, that metformin is associated with an increased risk of lactic acidosis, or with increased levels of lactate, compared to other anti-hyperglycaemic treatments, if prescribed under the study conditions, taking into account, the contra-indications. Although this study has significant limitations, it clearly suggests that metformin might be a less problematic therapy than originally anticipated.
Metformin-induced lactic acidosis is extremely rare in the absence of obvious risk factors. However, there are few cases of metformin-induced lactic acidosis in patients without pre-existing renal failure or other predisposing factors. (9),(10)

Signs and symptoms of metformin-induced lactic acidosis are non-specific and include anorexia, nausea, vomiting, altered level of consciousness, hyperpnoea, abdominal pain, and thirst. Lactic acidosis is characterized by elevat


In conclusion, lactic acidosis is a medical emergency that must be suspected in any diabetic patient with metabolic acidosis lacking evidence of ketoacidosis, even in the absence of obvious risk factors.


Wiholm BE, Myrhed M. Metformin-associated lactic acidosis in Sweden 1977-1991. Eur J Clin Pharmacol 1993;44: 589-91.
Gan SC, Barr J, Arieff AI, Pearl RG. Biguanide associated lactic acidosis. Case report and review of literature. Arch Intern Med 1992; 152: 2333-6.
Bailey CJ, Turner RC. Metformin. N Engl J Med 1996; 334: 574-9
Lee AJ. Metformin in non-insulin-dependent diabetes mellitus. Pharmacotherapy 1996; 16: 327-51.
McGuinness ME, Talbert RL. Phenformin induced lactic acidosis: a forgotten adverse drug reaction. Ann Pharmacother 1993; 27: 1183-7
Gowardman JR, Havill J. Fatal metformin induced lactic acidosis: case report. NZ Med J 1995; 108: 230-1.
Chan NN, Brain HPS, Feher MD. Metformin-associated lactic acidosis: a rare or very rare clinical entity? Diabet Med 1999; 16 (4):273-81.
Salpeter SR, Greyber E, Pasternak GA, et al. Risk of fatal and nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus: systematic review and meta-analysis. Arch Intern Med 2003;163: 2594–602.
al-Jebawi AF, Lassman MN, Abourizk NN. Lactic acidosis with therapeutic metformin blood level in a low-risk diabetic patient. Diabetes Care 1998; 21: 1364–5.
Ellis AK, Iliescu EA. Metformin-associated lactic acidosis in a low risk patient. Can J Clin Pharmacol 2001;8:104-6

Tables and Figures
[Table / Fig - 1]
JCDR is now Monthly and more widely Indexed .
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