Loading

Journal of Neurological Disorders and Stroke

Intravenous Thrombolysis in Two Patients with Acute Ischemic Stroke Treated with Chronic Hemodialysis

Case Report | Open Access | Volume 1 | Issue 3

Corresponding Authors
Abstract

Patients with renal failure have a higher risk for cerebrovascular events and silent brain damage and a higher cardiovascular mortality rate when compared with the general population. We present two cases where alteplase was used for hemodialysis patients (HP) with acute ischemic stroke (AIS).

A 70-year-old Caucasian female with a 2-year history of hemodialysis was admitted with right hemiparesis and aphasia (National Institutes of Health Stroke Scale, NIHSS: 15 pts.), which occurred during a hemodialysis session (HS). On the third day of hospitalization, after initial neurological improvement (NIHSS after 24 hours: 9 pts.), the patient died because of massive intestinal bleeding.

A 54-year-old Caucasian female with a 4-year history of hemodialysis was admitted after two incidents of ipsilateral transient ischemic attacks (TIA), which occurred between HSs. 30 min after admission, right hemiparesis and aphasia occurred (NIHSS: 16 pts. ). 3 months after stroke onset, the patient was functionally independent (NIHSS:2).

Keywords

Ischemic stroke; Thrombolysis; Brain damage; Hemodialysis; Renal insufficiency

Citation

Sobolewski P, ?ledzi?ska-D?wiga? M, Szczuchniak W, Sobota A, Hatalska-?erebiec R (2013) Intravenous Thrombolysis in Two Patients with Acute Ischemic Stroke Treated with Chronic Hemodialysis. J Neurol Disord Stroke 1(3): 1024.

INTRODUCTION

Renal insufficiency (RI) is highly prevalent in the general population [1,2]. Patients with RI, especially patients with renal failure, show abnormalities in coagulation and platelet function that favor thrombosis, but also augment bleeding risks [3]. Patients with even mild renal impairment suffer from complex hemostatic disorders including platelet hyperactivity, reduced tissue plasminogen activator dysfunction and von Willebrand factor abnormalities [4]. Thus, those patients have a higher risk for cerebrovascular events and silent brain damage and a higher cardiovascular mortality rate when compared with the general population [5,6].

Intravenous thrombolysis (IV-thrombolysis) with rt-PA is an effective therapy for acute ischemic stroke (AIS), but is associated with a number of hemorrhagic complications and is contraindicated in patients with severe hemostatic disorders [7]. We present two cases in which alteplase were used for hemodialysis patients (HP) with AIS.

CASES REPORT

A 70-year-old Caucasian female with a history of ischemic heart disease (IHD) and hypertension was on a maintenance dose of 75mg of aspirin per day. She had a 2-year history of hemodialysis. Routine hemodialysis sessions were carried out 3 times weekly. The patient was admitted with right hemiparesis and aphasia of 195-min duration (National Institutes of Health Stroke Scale, NIHSS: 15 pts. ), which occurred during a hemodialysis session (HS). During dialysis heparin was used. On admission, her blood pressure (BP) was 163/87 mmHg, and blood glucose, creatinine and hemoglobin levels were 6.49 mmol/L, 518.2 µmol/L and 13.7 g/L, respectively. The coagulation profile were as follows: International Normalized Ratio (INR) – 1.1, aPTT 30.6 sec. , Fibrinogen 3.05 g/L. In the baseline CT we found old ischemic changes (ICs). At 270 min after symptom onset, she received IV 40 mg rt-PA (weight estimated at 45 kg) without complications. After 24 hours, neurological improvement was observed (NIHSS: 9 pts. ). In the controlled CT, performed 24-h after thrombolysis, a small IC was located in the left temporal lobe (Figure 1a).

Brain CT scans of the 1st patient performed 24-h after stroke onset

Figure 1(a): Brain CT scans of the 1st patient performed 24-h after stroke onset 

During the next few days, standard dialysis was performed. On the 3rd day of hospitalization, the patient’s deterioration was noted; massive hemorrhage from the gastrointestinal tract was noted and the patient died.

A 54-year-old Caucasian female with a history of IHD, two incidences of myocardial infarction, hypertension, permanent atrial fibrillation and a prior ischemic stroke was on a maintenance dose of 150 mg of aspirin per day. She had a 4-year history of hemodialysis. Routine hemodialysis sessions were carried out 3 times weekly. The last dialysis took place 1 day before hospitalization. During dialysis heparin was used. The patient was admitted after two incidents of ipsilateral transient ischemic attacks (TIA), which occurred between HSs. 30 min after admission, right hemiparesis and aphasia occurred (NIHSS: 16 pts.). On admission, her BP was 170/90 mmHg, and blood glucose, creatinine and hemoglobin levels were 6.43 mmol/L, 553.8 µmol/L and 12.9 g/L, respectively. The coagulation profile was as follows: INR – 1.08, aPTT 26.4 sec., Fibrinogen 2.92 g/L. In the baseline CT we found an old IC, which was inconsistent with the current symptoms.

At 125 min after symptom onset, she received IV 40 mg rt-PA (weight estimated at 47 kg) without any complications. After 24 hours, neurological improvement was observed (NIHSS: 10 pts. ). A controlled CT, performed 24-h after thrombolysis, did not show any new IC or HT. Upon CT on the 7th day, a small IC was located in the left temporal lobe (Figure 1b).

Brain CT scans of the

Figure 1(b): Brain CT scans of the 2nd patient performed at 7th day

During next days, standard dialysis was performed. 3 months after stroke onset, the patient was functionally independent (NIHSS: 2).

DISCUSSION

It is believed that iv-thrombolysis is not a safe method of treatment of AIS in patients undergoing hemodialysis. The management of chronic HP, in whom AIS has occurred, is a great challenge. The previous clinical trials testing intravenous recombinant tissue-type plasminogen activator (rt-PA) for acute ischemic stroke did not specifically exclude hemodialysis patients, and major guidelines are silent on this issue [8-11]. There is no consensus regarding the impact of RI and especially renal failure on the effectiveness and safety of cerebral thrombolysis [12 14]. Patients with renal failure suffer from complex hemostatic disorders that are mainly due to abnormalities of primary hemostasis; in particular, platelet dysfunction and impaired platelet-vessel wall interaction [15]. HP has multiple risk factors and therefore they require many drugs. Additionally heparin is routinely used for dialysis circuit anticoagulation. However, the effect of unfractionated heparin can be monitored using the activated partial thromboplastin time (aPTT). Elevated aPTT after dialysis may lead to an increase in intra-cerebral hemorrhage (ICH) rate after IV rt-PA administration. It is recommended that the aPTT must be in the normal range if heparin has been given in the previous 48 hours [16-17]. Up to 34% of the ischemic stroke in patients on maintenance dialysis occur during or less than 30 minutes after the dialysis procedure [18]. Alignment of aPTT within a time window to 4.5 hours opens the way for use of alteplase in HP. Even between dialysis treatments, patients are predisposed to bleeding, suspected to be due to uremic platelet dysfunction [19].

Beyond the conventional stroke risk factors in HP, other non conventional factors are mentioned, such as: volume overload, anemia, oxidative stress, sympathetic over-drive, malnutrition, chronic inflammation (high c-reactive protein, low serum albumin), calcium, phosphate, parathyroid hormone levels disturbance and sleep disorders. Dialysis related factors are also specified, such as: hemodynamic, vascular access, dialysis amyloidosis, vascular calcification, dialysate (acetate) and dialysis vintage [20].

Only three case reports have mentioned the successful use of IV-thrombolysis in HP with AIS [21-23]. A recently published paper, by Tariq et al. showed no difference in the incidence of intra-cerebral hemorrhage (ICH) and the 2-fold higher odds of in-hospital mortality associated with administration of IV thrombolytics in dialysis-dependent patients who present with AIS. In this study, patients undergoing hemodialysis population numbered more than 1.000. The authors observed also that the percentage of patients with moderate-to-severe disability at the time of discharge was lower in the dialysis-dependent group, but this phenomenon was because of the increased inpatient mortality. The authors warranted a careful assessment of risk benefit ratio in this population [24].

Despite the concerns about bleeding risk and the absence of prospective controlled study, most surveyed stroke experts in thrombolytic therapy of acute ischemic stroke, favored using rt-PA in these patients. However, seventy-eight percent of the experts indicated the possibility of treating hemodialysis patients with intra-arterial approach and would have preferred mechanical clot retrieval to thrombolysis [25].

In our study, two female patients were treated with hemodialysis; one patient died on the third day of hospitalization because of massive intestinal bleeding, while the second had a good outcome. However, the adverse event occurred in the first patient during the subsequent hemodialysis session, in which heparin was used routinely. In addition, the patient continued to receive an aspirin. Older age and longer onset to treatment time were also important predictors of poor outcome in this case [26 28]. We believe that presented cases can bring certain values as assessment of safety of iv-thrombolysis in HP.

REFERENCES
  1. Nissenson AR, Pereira BJ, Collins AJ, Steinberg EP. Prevalence and characteristics of individuals with chronic kidney disease in a large health maintenance organization. Am J Kidney Dis. 2001; 37: 1177-1183.
  2. Garg AX, Kiberd BA, Clark WF, Haynes RB, Clase CM. Albuminuria and renal insufficiency prevalence guides population screening: results from the NHANES III. Kidney Int. 2002; 61: 2165-2175.
  3. Fox KA, Antman EM, Montalescot G, Agewall S, SomaRaju B, Verheugt FW, et al. The impact of renal dysfunction on outcomes in the ExTRACT-TIMI 25 trial. J Am Coll Cardiol. 2007; 49: 2249-2255.
  4. Jalal DI, Chonchol M, Targher G. Disorders of hemostasis associated with chronic kidney disease. Semin Thromb Hemost. 2010; 36: 34-40.
  5. Kuo CC, Lee CT, Ho SC, Kuo HW, Wu TN, Yang CY. Haemodialysis and the risk of stroke: A population-based cohort study in Taiwan, a country of high incidence of end-stage renal disease. Nephrology (Carlton). 2012; 17: 243-248.
  6. Weiner DE, Tighiouart H, Amin MG, Stark PC, MacLeod B, Griffith JL, et al. Chronic kidney disease as a risk factor for cardiovascular disease and all-cause mortality: a pooled analysis of community-based studies. J Am Soc Nephrol. 2004; 15: 1307-1315.
  7. Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008; 359: 1317-1329.
  8. [No authors listed]. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995; 333: 1581-1587.
  9. Hacke W, Kaste M, Fieschi C, Toni D, Ledaffre E, von Kummer R, et al. Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The ECASS Study Group. The European Cooperative Acute Stroke Study (ECASS). JAMA. 1995; 274: 1017-1025.
  10. Bluhmki E, Chamorro A, Davalos A, Machnig T, Sauce C, Wahlgren N, et al. Stroke treatment with alteplase given 3.0-4.5 h after onset of acute ischaemic stroke (ECASS III): additional outcomes and subgroup analysis of a randomised controlled trial. Lancet Neurol. 2009; 8: 1095-1102.
  11. IST-3 collaborative group Sandercock P, Wardlaw JM, Lindley RI, Dennis M, Cohen G, et al. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial. Lancet 2012; 379:2352-63.
  12. Naganuma M, Koga M, Shiokawa Y, Nakagawara J, Furui E, Kimura K, et al. Reduced estimated glomerular filtration rate is associated with stroke outcome after intravenous rt-PA: the Stroke Acute Management with Urgent Risk-Factor Assessment and Improvement (SAMURAI) rt-PA registry. Cerebrovasc Dis 2011; 31: 123-129.
  13. Agrawal V, Rai B, Fellows J, McCullough PA. In-hospital outcomes with thrombolytic therapy in patients with renal dysfunction presenting with acute ischaemic stroke. Nephrol Dial Transplant. 2010; 25: 1150-1157.
  14. Sobolewski P, Kozera G, Kaźmierski R, Michalak S, Szczuchniak W, Sledzińska-Dźwigał M, et al. Intravenous rt-PA in patients with ischaemic stroke and renal dysfunction. Clin Neurol Neurosurg. 2013; 115: 1770-1774.
  15. Boccardo P, Remuzzi G, Galbusera M. Platelet dysfunction in renal failure. Semin Thromb Hemost. 2004; 30: 579-589.
  16. Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL: Guidelines for the early management of adults with ischemic stroke. A guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Stroke. 2007; 38: 1655-1711.
  17. European Agency for the Evaluation of Medicinal Products: Actilyse.
  18. Toyoda K, Fujii K, Fujimi S, Kumai Y, Tsuchimochi H, Ibayashi S, et al. Stroke in patients on maintenance hemodialysis: a 22-year single-center study. Am J Kidney Dis. 2005; 45: 1058-1066.
  19. Sohal AS, Gangji AS, Crowther MA, Treleaven D. Uremic bleeding: pathophysiology and clinical risk factors. Thromb Res. 2006; 118: 417-422.
  20. seki K. Stroke feature and management in dialysis patients. Contrib Nephrol. 2013; 179: 100-109.
  21. Power A, Moser S, Duncan N. Successful thrombolysis for acute ischaemic stroke on haemodialysis. NDT Plus. 2010; 3: 576-578.
  22. McCloskey M, Masengu A, Shields J, Wiggam MI. Acute stroke in a patient with advanced uraemia: should thrombolysis be given? BMJ Case Rep. 2013; 2013.
  23. Naganuma M, Mori M, Nezu T, Makihara N, Koga M, Okada Y, et al.; on behalf of the Stroke Acute Management with Urgent Risk-Factor Assessment and Improvement (SAMURAI) Study Investigators. Intravenous recombinant tissue plasminogen activator therapy for stroke patients receiving maintenance hemodialysis: the Stroke Acute Management with Urgent Risk-Factor Assessment and Improvement (SAMURAI) rt-PA registry. Eur Neurol. 2011; 66: 37-41.
  24. Tariq N, Adil MM, Saeed F, Chaudhry SA, Qureshi AI. Outcomes of Thrombolytic Treatment for Acute Ischemic Stroke in Dialysis-Dependent Patients in the United States. J Stroke Cerebrovasc Dis. 2013; .
  25. Palacio S, Gonzales NR, Sangha NS, Birnbaum LA, Hart RG. Thrombolysis for acute stroke in hemodialysis: international survey of expert opinion. Clin J Am Soc Nephrol. 2011; 6: 1089-1093.
  26. Engelter ST, Reichhart M, Sekoranja L, Georgiadis D, Baumann A, Weder B, et al. Thrombolysis in stroke patients aged 80 years and older: Swiss survey of IV thrombolysis. Neurology. 2005; 65: 1795-1798.
  27. Mouradian MS, Senthilselvan A, Jickling G, McCombe JA, Emery DJ, Dean N, et al. Intravenous rt-PA for acute stroke: comparing its effectiveness in younger and older patients. J Neurol Neurosurg Psychiatry. 2005; 76: 1234-1237.
  28. Wardlaw JM, Murray V, Berge E, del Zoppo G, Sandercock P, Lindley RL, et al. Recombinant tissue plasminogen activator for acute ischaemic stroke: an updated systematic review and meta-analysis. Lancet. 2012; 379: 2364-2372.

Sobolewski P, ?ledzi?ska-D?wiga? M, Szczuchniak W, Sobota A, Hatalska-?erebiec R (2013) Intravenous Thrombolysis in Two Patients with Acute Ischemic Stroke Treated with Chronic Hemodialysis. J Neurol Disord Stroke 1(3): 1024.

Received : 02 Aug 2013
Accepted : 13 Sep 2013
Published : 13 Sep 2013
Journals
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
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
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
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
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
Author Information X