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

Users Online : 53944

AbstractCase ReportDiscussionReferences
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

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 : 2010 | Month : October | Volume : 4 | Issue : 5 | Page : 3217 - 3220

Chronic Thromboembolic Pulmonary Artery Hypertension With Deep Vein Thrombosis Due To Protein S Deficiency


*MD, Additional Professor of Medicine, KMC Mangalore, Manipal University; **MD, Assistant Professor of Medicine, KMC Mangalore, Manipal University; ***MD, Assistant Professor of Medicine, KMC Mangalore, Manipal University; ****MD, Assistant Professor of Medicine, KMC Mangalore, Manipal University, Department(s) and institution(s) : Medicine, Kasturba Medical College, Mangalore, Manipal University

Correspondence Address :
Dr. Nithyananda Chowta K
Associate Professor
Department of Medicine,
Kasturba Medical College, Mangalore, Manipal University
Mobile: 09845579112


A 30 year old male presented with the complaint of progressive dyspnoea. Cardiovascular examination showed tachycardia and loud second sound in the pulmonary area. ECG showed T wave inversion in lead III and chest X-ray showed dilatation of the pulmonary artery. Echocardiography showed mildly dilated right atrium/right ventricle, mild tricuspid regurgitation and moderate pulmonary arterial hypertension. Venous Doppler of the bilateral lower limbs showed deep vein thrombosis of both the lower limbs. HRCT (high resolution CT) showed pleural thickening in the apical segment of the left upper lobe and scattered ground glass attenuation in the apical basal segment of both the lower lobes, which were suggestive of thromboembolism. CECT (contrast enhanced CT) of chest showed pulmonary artery thrombosis of the left lower lobe segmental and interlobar artery. Protein S activity was 25 %( normal range: 77-143%), protein C activity was 82 %( normal range: 70-130%) and antithrombin III was 119(normal range: 80-120).

The protein C (PC) and protein S (PS) systems are the major regulatory systems of haemostasis. Protein C and protein S are vitamin K dependent proenzymes which are synthesized in the liver. The thrombin- thrombomodulin complex on the surface of endothelial cells is the site for the interaction with the proteins C and S. Protein C becomes activated after binding to these complexes. Protein S acts as a cofactor in this process. In contrast to PC, PS circulates in plasma in two forms. Approximately 60% of it is bound non-covalently to the complement component C4b binding protein; whereas, the remaining 40% is free. Only free PS has the APC cofactor activity(1). Activated protein C

(APC) inhibits factor VIIIa and factor Va, thus exhibiting its anticoagulant property and also enhances fibrinolysis through the inhibition of the plasminogen activator inhibitor. PS interacts with the complement system and may play a role in the phagocytosis of apoptotic cells. The impact of PS deficiencies on these non anticoagulant roles is not yet known. The prevalence of hereditary PS deficiency ranges from 0.03% to 0.13%.(2),(3)

Case Report

A 30 year old male presented with complaints of dyspnoea on exertion, of 3 week’s duration. The dyspnoea was of grade I-III, it was gradual in onset and was progressive. There was no history of orthopnoea/ paroxysmal nocturnal dyspnoea or history of diurnal or positional variation. The patient did not have chest pain, palpitations, syncope, cough, wheezing, fever, loss of weight or loss of appetite.

(Table/Fig 1)Chest X-ray: Dilatation of the pulmonary artery

The patient gave a history of chest pain, six weeks prior to the onset of the present complaints. The chest pain was of moderate intensity in the left lower chest, it was pricking in nature and lasted for 15 minutes. The pain was aggravated with respiration and was relieved spontaneously without medication. The chest pain was not radiating and was not associated with sweating, syncope, breathlessness or vomiting. There was no history of trauma/tuberculosis/asthma/hypertension/ diabetes mellitus/ ischaemic heart diseases/rheumatic or congenital heart diseases. There was no history of similar complaints in the past and also, no history of alcohol/smoking. The patient also gave a history of swelling in the calf, with pain 3 weeks prior to the onset of the present illness.

On physical examination, the patient’s blood pressure level was found to be 100/84 mm Hg, his pulse rate was 102/min and his body mass index was 23.85kg/m2. Respiratory, pulmonary, neurological, abdominal, and skin examination findings were unremarkable. Cardiovascular examination showed loud second sound in the pulmonary area.

ECG showed T wave inversion in lead III. Chest X-ray showed dilatation of the pulmonary artery (Fig 1). Echocardiography showed mildly dilated right atrium/right ventricle, mild tricuspid regurgitation and moderate pulmonary arterial hypertension. Venous Doppler of the bilateral lower limbs showed deep vein thrombosis (DVT) of the distal saphenous vein, the long saphenous vein of right lower limb, the distal saphenous vein and the popliteal vein of the left lower limb. HRCT (high resolution CT) showed pleural thickening in the apical segment of the left upper lobe and scattered ground glass attenuation in the apical basal segment of both the lower lobes, which were suggestive of thromboembolism (Fig 2). CECT (contrast enhanced CT) of chest showed pulmonary artery thrombosis of the left lower lobe segmental and interlobar artery (Fig3a and Fig 3b). Haemogram, erythrocyte sedimentation rate, blood sugar, kidney function tests, liver function tests, serum electrolytes and urine analysis were normal. Prothrombin time was normal (T-16seconds, C-14.8seconds, and INR-1). CPK-MB and tropinin T were also normal. Protein S activity was 25 % (normal range: 77-143%), protein C activity was 82% (normal range: 70-130%) and antithrombin III was 119 (normal range: 80-120). The levels of free and bound protein S could not be performed due to the patient’s financial constraints.

(Table/Fig 2) HRCT: Pleural thickening in the apical segment of left upper lobe and scattered ground glass attenuation in apical basal segment of both lower lobes

Based on these clinical findings and laboratory results, the patient was diagnosed to have chronic thromboembolic pulmonary artery hypertension with deep vein thrombosis due to protein S deficiency. The patient was started on warfarin 5mg daily and sildenafil 25mg daily.


PS deficiency may be quantitative or qualitative. The prevalence of hereditary PS deficiency in the general population remains largely unknown, probably because of its rarity and the difficulty of a correct diagnosis. However, a study in 3788 healthy Scottish blood donors showed a prevalence of hereditary PS deficiency ranging from 0.03% to 0.13%.(4) PS deficiency can be genetic (hereditary) or acquired.

(Table/Fig 3): CECT -CHEST
Pulmonary artery thrombosis of left lower lobe segmental and interlobar artery

In 1984, the first clinical report on PS deficiency as a risk factor for venous thromboembolism (VTE), was published.(5) Homozygous or compound heterozygous PS deficiency, though extremely rare, usually presents neonatally with massive VTE or purpura fulminans. Without treatment, this will be most likely to be lethal. Heterozygous PS deficiency is an established risk factor for VTE, but with incomplete and variable penetrance. The timing of presentation is usually before 50 years of age and the life-time risk of VTE is similar in men and women. However, probably because of the use of oral contraceptives and pregnancy or puerperium, PS-deficient women seem to be at a greater risk of developing VTE early in life (<30 years) as compared with PS-deficient men(2).

(Table/Fig 4): CECT -CHEST
Pulmonary artery thrombosis of left lower lobe segmental and interlobar artery

The acquired causes of protein C and S deficiencies are seen in acquired illnesses like liver disease, DIC, therapy with L-asparaginase and coumarin and acute severe bacterial infections, etc. The homozygous variety is rare and these patients have neonatal purpura fulminans(2).

Clinically, patients with protein C and S deficiencies are at an increased risk for venous thromboembolism (VTE), occasional arterial thrombosis, neonatal purpura fulminans, childhood stroke and even portal vein thrombosis. Women may have foetal loss as their only manifestation. 25% of the patients may experience arterial thrombosis, including stroke. Mortality is caused usually due to pulmonary embolism.(6),(7)

Generally, there are two types of PS assays: Immunoassays for the determination of total and free PS levels and clotting assays (functional assay) to measure the APC cofactor activity. APC cofactor activity determination results in a high rate of false-positive results because of the presence of APC resistance and high levels of prothrombin, FVIIIa and FVIIa. C4b-binding protein is an acute phase reactant, often elevated in thromboembolism, resulting in reduced free Protein S levels. Consequently, the measurement of protein S levels in acute thrombosis may yield misleading results. Immunological assays measure the levels of either total or free protein S. Immunological assays are useful in evaluating patients who have coexisting APC resistance (2).

The initial treatment consists of unfractionated heparin or LMWH, which is overlapped with warfarin until an international normalized ratio of 2.0–3.0 is reached on two consecutive days. Warfarin treatment should be considered for up to 2 years and even life-long in the presence of concomitant thrombophilic defects, whereas it should be usually continued for 3–6 months after the first VTE in patients without thrombophilia. Asymptomatic patients should not be treated, but should be considered for prophylaxis when they experience high-risk procedures such as surgery. Patients with massive thrombosis or pulmonary embolism require thrombolytic therapy(2).


Dahlback B. The tale of protein S and C4b-binding protein, a story of affection. Thromb Haemost 2007;98: 90–6.
Tenkate MK, van derMeer J. Protein S deficiency: a clinical perspective. Haemophilia 2008; 14: 1222–1228
Rezende SM, Simmonds RE, Lane DA. Coagulation, inflammation, and apoptosis: different roles for protein S and the protein S-C4b binding protein complex. Blood 2004; 103: 1192–201.
Dykes AC, Walker ID, McMahon AD, Islam SI, Tait RC. A study of Protein S antigen levels in 3788 healthy volunteers: influence of age, sex and hormone use, and estimate for prevalence of deficiency state. Br J Haematol 2001; 113: 636–41.
Schwarz HP, Fischer M, Hopmeier P, Batard MA, Griffin JH. Plasma protein S deficiency in familial thrombotic disease. Blood 1984; 64: 1297–300.
Brouwer JL, Veeger NJ, Kluin-Nelemans HC, van derMeer J. The pathogenesis of venous thromboembolism: evidence for multiple interrelated causes. Ann Intern Med 2006; 145: 807–15.
Van Vlijmen EF, Brouwer JL, Veeger NJ, Eskes TK, de Graeff PA, van derMeer J. Oral contraceptives and the absolute risk of venous thromboembolism in women with single or multiple thrombophilic defects: results from a retrospective family cohort study. Arch Intern Med 2007; 167: 282–9.

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)