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Journal of Clinical Nephrology and Research

Quality of Life Assessment using Sf-36 Questionnairre in Maintenance Hemodialysis Patients Supported by Government Funded Cashless Scheme

Research Article | Open Access | Volume 4 | Issue 3

  • 1. Gandhi Medical College, India
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Corresponding Authors
Manjusha Yadla, Gandhi Medical College, India, Tel: 040-23741265
Abstract

A cross sectional study was conducted to assess quality of life (QoL) in patients on maintenance hemodialysis at our centre. QoL was assessed using SF36 questionnairre. Patients who completed 6 months of hemodialysis were included in the study. Various predictors of total score, physical score and mental score were analysed. Secondary outcomes like number of hospitalizations and deaths were also analysed with each score. Vintage of dialysis had statistical significance with total score. Mental score was significantly impaired in those with diabetes mellitus.
 

Keywords

•    Hemodialysis •    Diabetes mellitus

CITATION

Yadla M (2017) Quality of Life Assessment using Sf-36 Questionnairre in Maintenance Hemodialysis Patients Supported by Government Funded Cashless Scheme. J Clin Nephrol Res 4(3): 1069.

INTRODUCTION

QoL is an important tool for measurement of outcomes of interventions done in patients with chronic illnesses. QoL is compromised due to different factors like logistics, finances, emotional well being, physical dependence, nutrition etc. Various tools and questionnaires are available to assess QoL in patients on hemodialysis. SF-36 has been one of the time tested questionnaires for assessment of QoL. It was estimated that 55000 patients were on dialysis in India by 2013 and number was expected to increase by 10-20% annually [1]. This would imply that there may be 66000-77000 patients on hemodialysis. Cost constraints, lack of infrastructure and man power are the major limiting factors for patients to access dialysis care facilities. In this background, our state government has initiated a cashless scheme of hemodialysis to all the patients below poverty line. QoL of these patients, who are daily laborers or jobless or dependents, would be expected to be on lower side as finances play significant role in maintaining quality of life.

This study was done prospectively to assess the physical component status and mental component status using SF-36 questionnairre in patients on maintenance hemodialysis run by State government for free of cost.

PATIENTS AND METHODS

The study was done in our center, where patients are supported by cashless government funded scheme, Aarogyasree, a flagship card scheme for poor patients, below poverty line. Since the time of inception of the scheme in the year 2007 till date, a total of 184899 therapies (State wide) were given by the government free of cost to the poor.(Courtesy: Aarogyasree website).

Under this scheme, patients are given thrice weekly hemodialysis of 10-12 sessions per month. Hemodialysis is done using 4008 Fresenius machine, F6 polysulfone dialyser. Each session is given for 4 hours. Average reuse of dialyser in our unit is 8. Patients are given weekly Erythropoietin injections. Hemoglobin, Kt/V, S. creatinine, viral markers is assessed periodically. The study follow up period was of one year.

Inclusion criteria: 

Age more than 18 years and less than 60 years

2. Duration of dialysis more than 6 months

Exclusion criteria: 

1. Duration of dialysis less than 6months

2. Age less than 18years

3. Those who have not given consent

4. Patients who were critically ill or pregnant, recent 
hospitalization, trauma, malignancy and active infection 

SF-36 measures the quality of life in multidimensional approach. SF 36 survey questionnaire (Medical Outcomes Study: 36-Item Short Form Survey) was assessed by department physicians in vernacular language Across eight domains of emotional and physical status: physical functioning; role limitations due to physical health; role limitations due to emotional problems; energy/fatigue; emotional well-being; social functioning; pain; general health, patients were asked to choose the best amongst the alternatives available. Data collected was compiled and the final score was given to each patient. Scoring was also assessed for PCS and MCS. Based on the total SF-36 score, depression was graded were graded.

Epidemiological data, vintage of dialysis, various comorbidities, dialysis data, vascular access and the laboratory parameters were studied. Based on total SF-36 score, patients were divided in to two groups. Secondary outcomes i.e. deaths, hospitalizations were also assessed.

 

STATISTICAL ANALYSIS

Statistical analysis was done using the SPSS package, version 20. Results were done by Chi-square test. Significance was considered for P < 0.05.Pearson correlation test and multiple logistic regression analysis were used to analyze the variables.

RESULTS

Of 150 patients in our center, 130 patients satisfied inclusion criteria and could answer the questionnaire.

Mean age of the group was 43.6 ± 11.9 years and 70% of them were men (92/130). Mean duration of dialysis was 29.48 ± 22.8 months (median duration: 24 months, range: 6months – 8 years). Moderate depression (SF score <50) was found in 48.4% (Table 1)

Table 1: Grading of depression and percentage distribution.

Score Grading N (%)
<25 Severe depression 0
25-50 Moderate depression 63(48.4%)
51-75 Mild depression 60(46%)
>75 Good health 7 (5.3%)

and severe depression was not found in any of the patients. Severity of depression was assessed in different age groups, of which patients with mild- moderate depression were between 30-60 years (Figure 1).

SF-36 score distribution between different age groups.

Figure 1 SF-36 score distribution between different age groups.

Table (2) shows base line characteristics and the total SF36 score.

Table 2: Baseline characteristics and total SF-36 score.

Variable Status                       SF Score % P Value OR
<50 (63) (%) ≥50 (67) (%)
Gender F 14 (22.2) 24(35.8) 0.13 0.5
(0.23-1.11)
M 49 (77.8) 43 (64.2)
BMI 18-25 38 (60.3) 42 (62.7) 0.90

0.9

(0.44-1.83)

<18 or>25 25 (39.7) 25 (37.3)
Duration < 24 m 35 (55.6) 23 (34.3) 0.02

2.3

(1.17-4.85)

≥ 24m 28 (44.4) 44 (65.7)
HTN Y 39(61.9) 43 (64.2) 0.93

0.9

(0.44-1.84)

N 24(38.1) 24 (35.8)
DM Y 32 (50.8) 27 (40.3) 0.30

1.52

(0.76-3.06)

N 31 (49.2) 40 (59.7)
LVD Y 32 (50.8) 33 (49.3) 0.86

1.06

(0.53-2.11)

N 31 (49.2) 34 (50.7)
PVD Y 28 (44.4) 32 (47.8) 0.83

0.87

(0.43-1.74)

N 35 (55.6) 35 (52.2)
CVA Y 15 (23.8) 22 (32.8) 0.34

0.63

(0.29-1.38)

N 48 (76.2) 45 (67.2)
PTB Y 5 (7.93) 3 (4.5) 0.64

1.83

(0.42-8.03)

N 58 (92.1) 64 (95.5)
HBV Y 1 (1.6) 5 (7.5) 0.23

0.2

(0.02-1.76)

N 62 (98.4) 62 (92.5)
HCV Y 10 (15.9) 11 (16.4) 0.87

0.96

(0.37-2.44)

N 53 (84.1) 56 (83.6)
S. CR >5mg 27 (42.9) 20 (29.9) 0.17

0.76

(0.85-3.63)

<5mg 36 (57.1) 47 (70.1)
Hb <10gm 41 (65.1) 52 (77.6) 0.16

0.53

(0.24-1.16)

>10gm 22 (34.9) 15 (22.4)
HD Access AVF 49 (77.8) 59 (88.1) 0.18

0.47

(0.18-1.22)

IJV 14 (22.2) 8 (11.9)
Wt. Loss Y 42 (66.7) 34 (50.7) 0.09

1.94

(0.96-3.94)

N 21 (33.3) 33 (49.3)
Smoking Y 31 (49.2) 26 (38.8) 0.30

1.52

(0.76-3.06)

N 32 (50.8) 41 (61.2)
Kt/v <1.2 40 (63.5) 40 (59.7) 0.79

1.17

(0.57-2.38)

>1.2 23 (36.5) 27 (40.3)
IDWG 1-3kg 30 (47.6) 36 (53.7) 0.60

0.78

(0.39-1.55)

>3kg 33 (52.4) 31 (46.3)
ID Hypo Y 36 (57.1) 33 (49.3) 0.46

1.37

(0.68-2.74)

N 27 (42.9) 34 (50.7)

Based on total SF score, moderate – severe depression was observed in 48.4%. Of 130 study population, 50% had MCS score <50 and 39%had PCS score <50. Depression was found to be significant in those with vintage <24 months (p=0.015) and also in those with diabetes (p=0.008). A similar finding was noted with mental health status. A poor mental health was noted inpatients with diabetes (p=0.002)

Amongst the variables, depression was significant in those with longer vintage of dialysis (p<0.05). Other variables like diabetes, serum creatinine, weight loss and smoking were not found to be statistically significant. Age, gender, comorbities like diabetes, peripheral vascular disease, left ventricular dysfunction, serological status, hemoglobin, serum creatinine did not differ between the two groups. Amongst the lab parameters, mean serum calcium score of the study group was 8.2 ± 1.2mg/dl and serum phosphorus was 2.5 ± 1.3mg/dl.

Analysis of individual scores of SF-36 shows that role limitation for physical health (RLPH) and emotional problems (RLEP) varied widely as 51 % of the group had low score of 75 (Figure 2). Worst scores (75) are seen in social functioning, and bodily pain (Figure 2).

Distribution of all eight components of SF-36 score

Figure 2 Distribution of all eight components of SF-36 score

Both the physical and mental health scores were assessed independently. Various predictors of Physical health score (PH) are shown in Table (3).

Table 3: Various predictors and PH score.

Variable Status  PH Score % P Value OR
<50 (51) ≥50 (79)
Gender F 13 (25.5) 25 (31.6) 0.57

0.73

(0.33-1.62)

M 38 (74.5) 54 (68.4)
BMI 18-25 30 (58.8) 50 (63.3) 0.74

0.82

(0.40-1.70)

<18 or ≥25 21 (41.2) 29 (36.7)
Duration < 24 m 26 (51.0) 32 (40.5) 0.32

1.52

(0.75-3.10)

≥ 24m 25 (49.0) 47 (59.5)
Hypertension Y 28 (54.9) 54 (68.4) 0.17

0.56

(0.27-1.16)

N 23 (45.1) 25 (31.6)
DM Y 21 (41.2) 38 (48.1) 0.30

1.52

(0.76-3.06)

N 30 (58.8) 41 (51.9)
LVD Y 22 (43.1) 43 (54.4) 0.28

0.63

(0.31-1.29)

N 29 (56.9) 36 (45.6)
PVD Y 22 (43.1) 38 (48.1) 0.70

0.81

(0.40-1.66)

N 29 (56.9) 41 (51.9)
CVA Y 12 (23.5) 25 (31.6) 0.42

0.66

(0.29-1.48)

N 39 (76.5) 54 (68.4)
PTB Y 3 (5.9) 5 (6.3) 0.18

0.92

(0.21-4.05)

N 48 (94.1) 74 (93.7)
HBV Y 1 (2.0) 5 (6.3) 0.46

0.29

(0.03-2.61)

N 50 (98.0) 74 (93.7)
HCV Y 6 (11.8) 15 (19.0) 0.39

0.56

(0.20-1.57)

N 45 (88.2) 64 (81.0)
S. Cr(mg/dl) >5 25 (49.0) 22 (27.8) 0.02

2.49

(1.19-5.20)

<5 26 (51.0) 57 (72.2)
Hb(gm/dl) <10 33 (64.7) 60 (75.9) 0.23

0.58

(0.26-1.25)

>10 18 (35.3) 19 (24.1)
HD Access AVF 42 (82.4) 67 (84.8) 0.89

0.83

(0.32-2.15)

IJV 9 (17.6) 12 (15.2)
Wt. Loss Y 32 (62.7) 44 (55.7) 0.53

1.33

(0.65-2.75)

N 19 (37.3) 35 (44.3)
Smoking Y 21 (41.2) 36 (45.6) 0.75

0.83

(0.41-1.70)

N 30 (58.8) 43 (54.4)
Kt/v <1.2 35 (68.6) 45 (57.0) 0.25

1.65

(0.78-3.46)

>1.2 16 (31.4) 34 (43.0)
IDWG 1-3kg 27 (52.9) 39 (49.4) 0.82

1.15

(0.57-2.33)

3kg 24 (47.1) 40 (50.6)
ID Hypo Y 27 (52.9) 42 (53.2) 0.87

0.99

(0.48-2.00)

N 24 (47.1) 37 (46.8)

PH score was <50 in 39.23%. Low serum creatinine of <5mg/dl was found to be statistically significant with PH score. Though Odds ratio for diabetes, Kt/v, weight loss was found to be high, P value was not found to be significant.

Table (4) shows various predictors of mental health score. Diabetes was found to be statistically significant with the MH score (P =0.002).Other variables like vintage of dialysis, serum creatinine, smoking, intradialytic hypotension were found to have high odds ratio, but p value was not significant.

Table 4: Predictors and MH score.

Variable Status MH Score % P Value
 
OR
 
<50 (66) ≥50 (64)
Gender F 17 (25.8) 21 (32.8) 0.48

0.71

(0.33-1.51)

M 49 (74.2) 43 (67.2)
BMI 18-25 39 (59.1) 41 (64.1) 0.68

0.81

(0.39-1.64)

<18 or ≥25 27 (40.9) 23 (35.9)
Duration < 24 m 32 (48.5) 26 (40.6) 0.46

1.37

(0.68-2.75)

≥ 24m 34 (51.5) 38 (59.4)
Hypertension Y 43 (65.2) 39 (60.9) 0.75

1.19

(0.58-2.44)

N 23 (34.8) 25 (39.1)
DM Y 43 (65.2) 24 (37.5) 0.002

3.11

(1.52-6.37)

N 23 (34.8) 40 (62.5)
LVD Y 34 (51.5) 31 (48.4) 0.86

1.13

(0.56-2.25)

N 32 (48.5) 33 (51.6)
PVD Y 30 (45.5) 30 (46.9) 0.98

0.94

(0.47-1.88)

N 36 (54.5) 34 (53.1)
CVA Y 15 (22.7) 22 (34.4) 0.20

0.56

(0.25-1.21)

N 51 (77.3) 42 (65.6)
PTB Y 6 (9.1) 2 (3.1) 0.29

3.1

(0.60-15.96)

N 60 (90.9) 62 (96.9)
HBV Y 2 (3.0) 4 (6.3) 0.64

0.46

(0.08-2.65)

N 64 (97.0) 60 (93.8)
HCV Y 12 (18.2) 9 (14.1) 0.68

1.35

(0.52-3.48)

N 54 (81.8) 55 (85.9)
S. CR >5mg 28 (42.4) 19 (29.7) 0.18

1.79

(0.84-3.60)

<5mg 38 (57.6) 45 (70.3)
Hb <10g 46 (69.7) 47 (73.4) 0.78

0.83

(0.38-1.78)

>10g 20 (30.3) 47 (73.4)
HD Access AVF 52 (78.8) 56 (87.5) 0.27

0.53

(0.20-1.36)

IJV 14 (21.2) 8 (12.5)
Wt. Loss Y 41 (62.1) 35 (54.7) 0.49

1.35

(0.67-2.73)

N 25 (37.9) 29 (45.3)
Smoking Y 34 (51.5) 23 (35.9) 0.10

1.89

(0.93-3.82)

N 32 (48.5) 41 (64.1)
Kt/v <1.2 42 (63.6) 38 (59.4) 0.74

1.19

0.59-2.42)

>1.2 24 (36.4) 26 (40.6)
IDWG 1-3kg 32 (48.5) 34 (53.1) 0.72

0.83

(0.41-1.65)

>3kg 34 (51.5) 30 (46.9)
ID Hypo Y 38 (57.6) 31 (48.4) 0.30

1.44

(0.72-2.88)

N 28 (42.4) 33 (51.6)

Secondary outcomes like deaths and hospitalizations were analysed. Correlation of secondary outcomes with total score, PH score and MH score was done (Table 5).

Table 5: Secondary outcomes with total score, PH score and MH scores.

Total score P value OR
No.of Hosp >3 43 (68.3) 48 (71.6) 0.81

0.85

(0.40-1.80)

(1-3) 20 (31.7) 19 (28.4)
Deaths Y 9(14.3) 10 (14.9) 0.88 0.95
(0.35-2.51)
PH score  
No.of Hosp >3 36 (70.6) 55 (69.6) 0.93

1.04

(0.48-2.26)

(1-3) 15 (29.4) 24 (30.4)
Deaths Y 8 (15.7) 11 (13.9) 0.98

1.15

(0.42-3.08)

N 43 (84.3) 68 (86.1)
MH score  
No.of Hosp >3 47 (71.2) 44 (68.8) 0.90

1.12

(0.53-2.38)

(1-3) 19 (28.8) 20 (31.3)
Deaths Y 12 (18.2) 7 (10.9) 0.35

1.80

(0.66-4.93)

N 54 (81.8) 57 (89.1)
Abbreviations: IDWG: Interdialytic Weight Gain; IDH: Intradialytic Hypotension; LVD; Left Ventricular Dysfunction; PVD: Peripheral Vascular Disease; PTB: Pulmonary Tuberculosis; CVA: Cerebrovascular Accident; DM: Diabetes Mellitus; S.CR: Serum Creatinine; HBV: Hepatitis B; HCV: Hepatitis C; Hb: Hemoglobin; No. of Hosp: Number of Hospitalizations; PH: Physical Health; MH: Mental Health; RLEP: Role Limitation In Emotional Problems; RLPH: Role Limitation In Physical Health; EF: Energy Fatigue; BP: Bodily Pain; GH: General Health; EWB: Emotional Well Being; SF: Social Functioning

Though P value for the outcomes was not found to be significant with all the 3 scores, odds ratio was high with MH score on deaths.

DISCUSSION

Assessment of QoL is important in patients of chronic illnesses placed on intervention modalities. QoL is shown to be one of the important factors influencing morbidity and mortality in those on renal replacement therapies. WHO has defined QoL as individual’s perception of their position in life in context of cultural and value systems in which they live in and in relation to their goals, expectations, standards and concerns [2].

SF-36 is a commonly used tool to assess the QoL of patients on MHD. QoL in these patients is affected not only by the quality and adequacy of dialysis but also by anemia correction, nutrition, availability of finances, emotional dependence. Assessment of physical health depends on the physical activities and assessment of mental health depends on extent of depression. Depression has been one of the most disabling morbidity in this group. Hence the score was categorized in to mild, moderate and severe depending on the SF score.

Limited studies are reported from India regarding QoL in maintenance dialysis patients. Veerappan et al., studied QoL in 78 patients on dialysis [3-5]. Vettath et al., in a study of QoL in 60 patients on hemodialysis observed that depression was influenced by poverty, frequency of dialysis, erythropoietin usage [5]. Our group is different from the previous study in that though all the patients in our study are below poverty line, they are given 8-10 free hemodialysis sessions along with free erythropoietin.

Gender influence with females having worser scores was reported in both the studies. But we did not find gender influence in any of the scores.

In our study, we did not observe influence of various comorbidities like PVD, CVA, LVD, DM, PTB on total score, and physical score. But patients with diabetes were found to have low mental health score (P=0.002). This is in concordance with the study by Vettath et al.

A poor QoL was found to be associated with low serum albumin, low serum hemoglobin, low protein catabolic rate and severe degree of malnutrition [4-6]. In our group physical score was poor in those with serum creatinine less than 5mg/dl.

We could not find the significance of anemia with any of the scores though the incidence of anemia continued to be high (71%).This higher incidence and lack of statistical significance could be due to presence of equal number in both the groups and a higher cut off value of 10 gm/dl.

Dialysis parameters like Kt/V, IDWG, IDH did not show significance with the scores. In our study, we could not find the significance of scores on deaths or hospitalizations [7,8].

A poor QoL was correlated with severe malnutrition, low serum albumin, low serum creatinine and anemia (6,7,8).In our study, we could not assess serum albumin , protein catabolic rate, other serum parameters like serum iPTH, vitamin D status , CRP, regular liver function tests. Low PH scores were observed with low serum creatinine as physical health is significantly influenced by nutrition, indirectly by muscle mass and thus the creatinine.

In our study, we did not find the Physical score, mental score or the total score predicting deaths or hospitalizations unlike in many other studies, where mental scores and physical scores were significantly associated with mortality [9-15]. But we observed that presence of lower mental score has a slightly higher chance of mortality (OR=1.8).This could be due to small sample size of the study population.

CONCLUSIONS

1. Moderate to severe depression was found in 48% despite provision of free hemodialysis sessions in required number.
2. Duration of dialysis remains the statistically significant factor for poor SF-36 scores.
3. Diabetes mellitus and serum creatinine, are the statistically significant factors for mental health and physical health respectively.
 

LIMITATIONS

1. Small number of population study.

2. All the biochemical parameters could not be assessed as they are not funded by the government scheme.

ACKNOWLEDGEMENTS

We acknowledge the immense help by Dr. Mahesh and Dr. Raju for analysing the statistics of the study.

REFERENCES

1. Jha V. Current status of end-stage renal disease care in India and Pakistan. Kidney International Supplements. 2013; 3: 157-160.

2. WHOQOL, World Health Organization. Measuring Quality of Life: The Development of the World Health Organization Quality of Life Instrument (WHOQOL). 1993.

3. Sathvik BS, Parthasarathi G, Narahari MG, Gurudev KC. An assessment of the quality of life in hemodialysis patients using the WHOQOL-BREF questionnaire. Indian J Nephrol. 2008; 18: 141-149.

4. Veerappan I, Arvind RM, Ilayabharthi V. Predictors of quality of life of hemodialysis patients in India. Indian J Nephrol. 2012; 22: 18-25.

5. Vettath RE, Reddy YN, Reddy YN, Dutta S, Singh Z, Mathew M, et al. A multicenter cross-sectional study of mental and physical health depression in MHD patients. Indian J Nephrol. 2012; 22: 251-256.

6. Laws RA, Tapsell LC, Kelly J. Nutritional status and its relationship to quality of life in a sample of chronic hemodialysis patients. J Ren Nutr. 2000; 10: 139-147.

7. Lowrie EG, LePain L, Zhang H, Lew NL, Lazarus JM. Preliminary evaluation of the SF-36 among hemodialysis patients. (Fresenius Medical Care Memorandum to Dialysis Services Division Medical Directors. Lexington MA) 1997. Memorandum provided online as Supplementary Material to the February 2000 AJKD contents.

8. Ohri-Vachaspati P, Sehgal AR. Quality of life implications of inadequate protein nutrition among hemodialysis patients. J Ren Nutr. 1999; 9: 9-13.

9. Kimmel PL, Peterson RA, Weihs KL, Simmens SJ, Alleyne S, Cruz I, et al. Multiple measurements of depression predict mortality in a longitudinal study of chronic hemodialysis outpatients. Kidney Int. 2000; 57: 2093-2098.

10. Kimmel PL, Peterson RA, Weihs KL, Shidler N, Simmens SJ, Alleyne S, et al. Dyadic relationship conflict, gender, and mortality in urban hemodialysis patients. J Am Soc Nephrol. 2000; 11: 1518-1525.

11. Reuben DB, Rubenstein LV, Hirsch SH, Hays RD. Value of functional status as a predictor of mortality: results of a prospective study. Am J Med. 1992; 93: 663-669.

12. Bernard SL, Kincade JE, Konrad TR, Arcury TA, Rabiner DJ, Woomert A, et al. Predicting mortality from community surveys of older adults: the importance of self-rated functional ability. J Gerontol B Psychol Sci Soc Sci. 1997; 52: 155-163.

13. McClellan WM, Anson C, Birkeli K, Tuttle E. Functional status and quality of life: Predictors of early mortality among patients entering treatment for end stage renal disease. J Clin Epidemiol. 1991; 44: 83- 89.

14. Ifudu O, Paul HR, Homel P, Friedman EA. Predictive value of functional status for mortality in patients on maintenance hemodialysis. Am J Nephrol. 1998; 18: 109-116.

15. DeOreo PB. Hemodialysis patient assessed functional health status predicts continued survival, hospitalization, and dialysis-attendance compliance. Am J Kidney Dis. 1997; 30: 204-212.

Yadla M (2017) Quality of Life Assessment using Sf-36 Questionnairre in Maintenance Hemodialysis Patients Supported by Government Funded Cashless Scheme. J Clin Nephrol Res 4(3): 1069.

Received : 26 May 2017
Accepted : 27 Jun 2017
Published : 29 Jun 2017
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Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
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