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

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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.
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Dr. Mamta Gupta
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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.
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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.
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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

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : November | Volume : 16 | Issue : 11 | Page : OC28 - OC30 Full Version

Neutrophil to Lymphocyte Ratio among Acute Ischaemic Stroke Patients

Published: November 1, 2022 | DOI:
Mustaq Ahmed, Siva Ranganthan Green, Siddharth Pugalendhi, Dhruvi Reddy Sanikommu

1. Senior Resident, Department of Internal Medicine, Sri Venkateshwara Medical College and Hospital, Puducherry, India. 2. Professor, Department of Internal Medicine, Mahatma Gandhi Medical College and Research Institute, SBV University, Puducherry, India. 3. Assistant Professor, Department of Internal Medicine, Mahatma Gandhi Medical College and Research Institute, SBV University, Puducherry, India. 4. Resident, Department of Internal Medicine, Mahatma Gandhi Medical College and Research Institute, SBV University, Puducherry, India.

Correspondence Address :
Dr. Siva Ranganthan Green,
1C, Type 1 Staff Quarters, MGMCRI Campus, Puducherry, India.


Introduction: Finding potential prognostic indicators for Acute Ischaemic Stroke (AIS) may help to increase the accuracy with which outcomes can be predicted, and implementing early therapies may help to improve the prognosis as well. Recently, Neutrophil Lymphocyte Ratio (NLR) was shown to predict short-term outcome in patients with AIS.

Aim: To determine whether NLR is useful in detecting length of stay, complications in the hospital and three months outcome of a patient admitted with AIS.

Materials and Methods: This was a prospective cohort clinical study that was conducted in the Department of General Medicine, Mahatma Gandhi Medical College and Research Institute, a tertiary care hospital, Pillaiyarkuppam, Puducherry, India where 62 AIS patients were enrolled between December 2019-May 2021. All the routine blood investigations and NLR was calculated during admission and on day five, The patients were followed-up for the next three months. During the course of their stay in the hospital, patients were assessed daily using the National Institutes of Health Stroke Scale (NIHSS).

Results: The mean age of the study population was 67.48±11.29 years, with 37 (59.68%) males and 25 (40.32%) females. The mean NLR on day 1 and day 5 were 5.42±2.85 and 3.51±1.97, respectively. There was a positive correlation between NLR and length of hospital stay (r=0.9661; p<0.0001). Patients having NLR >8, were observed to have complications such as aspiration pneumonia 3 (33%), seizures 2 (22%), and urinary tract infection 1 (11%).

Conclusion: NLR is useful marker in detecting length of stay, complications in the hospital and three months outcome of a patient admitted with AIS.


Inflammation, National institutes of health stroke scale, Prognosis, Stroke

Inflammation plays a crucial role in the pathophysiology of acute ischaemic stroke. Among such inflammatory markers, the NLR is identified as a critical indicator of systemic inflammation (1). Decreasing the leukocyte adherence, via targeting of multiple adhesion molecules, prevents leukocytes from entering ischaemic brain, and resulting in decreased neurologic damage (2). NLR has been extensively explored as a predictive factor because it is inexpensive and the investigations are routinely done (2),(3),(4).

Numerous meta-analyses have established that an elevated NLR level is a poor prognostic predictor in patients with AIS and spontaneous intracerebral haemorrhage (5),(6),(7),(8). Brooks SD et al., conducted a retrospective cohort research in 2014 and discovered that NLR 5.9 was associated with a poor outcome and mortality at 90 days (9). However, another multicentre study conducted by Duan Z et al., demonstrated that NLR 7.0 was independently related with poor functional outcome and that there was no significant correlation between NLR level and three month death (10).

This study aimed to bridge the gap in literature and to provide an overview about the role of NLR in ischaemic stroke, its correlation with duration of in-hospital stays, complications, and three month outcome of the patient. This can help clinicians use this novel biomarker in their everyday practice and impact early diagnosis in such cases.

Material and Methods

This was a prospective cohort clinical study that was conducted in the Department of General Medicine, Mahatma Gandhi Medical College and Research Institute, a tertiary care hospital, Pillaiyarkuppam, Puducherry. Total of 62 patients were enrolled between December 2019-May 2021. The study was started after obtaining the approval of Institutional Human Ethical Committee (MGMCRI/Res/01/2019/35/IHEC/111) on 09.03.2020.

Inclusion criteria: AIS patients above 18 years presenting to the institution, within less than three days of onset of symptoms were included in the study.

Exclusion criteria: Pregnant and lactating females, patients with acute or chronic infections, deranged liver and renal parameters, major trauma and surgery, cancer, haematologic disease or use of any immunosuppressants were excluded from the study.

Study Procedure

Patients who fell under the selection criteria and voluntarily agreed to be involved in the study were enrolled. Informed consent was obtained from each patient recruited for this study after explaining the nature of the study and the possible investigations involved. A complete history of the patient was obtained regarding the onset of stroke, with associated co-morbidities. Then physical examination was carried out including general examination and vitals. All routine blood investigations such as complete blood count, blood urea, serum creatinine, serum electrolytes, random blood sugar, fasting blood sugar, postprandial and HbA1c etc. NLR was calculated on the day of admission and on day five. Then every patient was followed-up for the next three months through regular telephonic conversations and outpatient visits. During the course of the stay in the hospital, patients were assessed daily using the NIHSS (11).

The patients were categorised based on NLR values as

• ‘good’ (>3 to 5.9),
• ‘fair’ (6 to 8.9), and
• ‘poor’ (>9) (12),

then were compared with the length of hospital stay to identify the precise NLR values.

They were treated with anticoagulants, antiplatelets, and statins along with regular physiotherapy. If the patients had any co-morbidities such as diabetes, hypertension was controlled by Oral Hypoglycaemic Agents (OHA)/Insulin and antihypertensives, respectively.

Statistical Analysis

The data was entered in an excel sheet. Data was exported to Medcalc version 19.0 for further processing. All categorical variables were expressed as percentages and the continuous variables were expressed as mean±standard deviation. The statistical significance of mean differences was compared in three groups using a one-way ANOVA analysis. The Pearson’s correlation analysis was also done. A p-value <0.05 was considered to be significant.


The mean age of the study population was 67.48±11.29 years, with 37 (59.68%) males and 25 (40.32%) females. Smoking habits was observed in 40.32% of the patients, and 37.09 % patients had a history of alcohol consumption. Diabetes mellitus was observed in 40.32%, and 71% patients were hypertensive (Table/Fig 1).

The complete blood count, NLR and NIHSS are illustrated in (Table/Fig 2). The mean NLR on day 1 and day 5 were 5.42±2.85 and 3.51±1.97, respectively, which showed a significantly decreasing trend.

The NLR values of admission day were categorised into three groups as ->3 to 5.9, 6 to 8.9, and >9. Each group was compared with the length of hospital stay. It was observed that when NLR values increased at the day of admission, the length of hospital stay also increased (Table/Fig 3).

Complications were analysed among the three groups based on NLR. The first two groups (>3-5.9 and 6-8.9) did not have any complications (Table/Fig 3). Whereas, in the third group (NLR >9), there were complications such as aspiration pneumonia, seizures, urinary tract infection, deep vein thrombosis, and haemorrhagic transformation. There were total nine patients in third group out of which one patient passed away due to aspiration pneumonia which signifies that NLR value >9 increases duration of hospital stay and also have high risk of complications including mortality.

The outcome of the study patients was analysed using NIHSS score. The patients were grouped based on NLR values and each group was compared with the length of hospital stay to identify the precise NLR values.The mean NLR values positively correlated with increased length of hospital stay in NLR group >9 (r=0.9661; p<0.0001), with a poorer three month outcome (Table/Fig 3).


Stroke is the most common disabling and fatal disease in adults. More than 40% surviving stroke patients have neurological deficit symptoms and need to be cared for (13). The factors that affect the prognosis of the patients are the severity of stroke and old age. In addition, infection has a negative effect on the outcome, which plays an important role in extending hospital stay, worsening of neurological outcome, developing more serious complications and death (14),(15).

Hence, this study evaluated the demographic, vascular risk factors, NLR, duration of the stay, complications and three month outcome with relation to admission NLR. The NLR values of day one came down significantly on day five. Lee H et al., demonstrated that measurement of NLR serially, and not only on admission but also on day four, predicts the prognosis and early treatment response (16). Kaushik R et al., demonstrated that a high NLR value at the end of late phase (day 5) had a poor outcome and prolonged duration of ICU stay and thus concluded that late phase value of this inflammatory biomarker is helpful in detecting the prognosis in sepsis (17).

Celikbilek A et al., found that the NLR levels were higher in patients with AIS when compared to the controls (p-value=0.001) (12). But different studies used varying cut-off values for NLR, so in this study the patients were grouped based on NLR values between 3-5.9, 6-8.9, and >9. Each group was compared with the length of hospital stay to identify the precise NLR values. The summary of the observations revealed that, when NLR values are high at the day of admission, the length of hospital stay was prolonged. Similarly, Zhao L et al., found that the NLR cut-off NLR value of 2.9 would mean a prolonged length of hospital stay (18). However, in this study, they have not mentioned about the complications and prognosis. Günes M et al., also found a positive correlation between NLR (cut-off value of 4.43), length of hospital stay and morbidity (19). Although, in the present study, the patients were admitted for observation despite no complications that might have reflected on the duration of hospital stay.

In the group with NLR >9, out of nine patients, eight had complications. He L et al., determined that patients with NLR >5.79 had more poststroke infections but in the present study, there were no complications in this particular range (20). Goyal N et al., studied NLR values at the time of admission in AIS patients with large vessel occlusion and reported that NLR >8.5 had intracranial haemorrhage, NLR >5.79 had increased 3 month mortality and NLR >4.4 had poor functional outcome at three months (21). This was probably due to the procedure of mechanical thrombectomy that the patients had undergone.

In this study, the mean NLR values positively correlated with a good three month outcome in NLR >3-5.9 group. The higher the NLR, (>5.9) the worse was the three month outcome. Overall, if the NLR values were high at the day of admission, the overall three month outcome was poor. Similarly, Celikbilek et al., also concluded that a cut-off value of 4.1 for NLR can be used as a predictive biomarker for worse outcome in AIS (12). Cai W et al., found that NLR positively correlated with higher NIHSS and infarct sizes, and determined that NLR >12.1±4.5 had a poor prognosis (22). Brooks SD et al., also found a significant relationship between NLR ≥5.9, poor outcome, and death at 90 days (9). All the three above-mentioned studies reported a statistically significant correlation between NLR values and overall prognosis of AIS.


The sample size was limited. All patients were classified under moderate stroke (NIHSS- 4 to 24), mild (NIHSS <4), and severe (NIHSS >21) form of stroke was not included in the study.


The NLR level is an ensuring marker of stroke prognosis. This study showed a significant correlation between raised NLR values with increased length of hospital stay, complications and three month outcome of the patient. Early inflammatory response of neutrophils and lymphocytes can predict clinical outcome of stroke patients. NLR is inexpensive and easily calculated from complete haemogram which helps clinicians stratify risk and initiate early treatment, thus preventing complications.


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DOI and Others

DOI: 10.7860/JCDR/2022/56872.17144

Date of Submission: Apr 05, 2022
Date of Peer Review: May 13, 2022
Date of Acceptance: Aug 24, 2022
Date of Publishing: Nov 01, 2022

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

• Plagiarism X-checker: Apr 14, 2022
• Manual Googling: Aug 13, 2022
• iThenticate Software: Aug 19, 2022 (16%)

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