Loading

Journal of Veterinary Medicine and Research

Stress Assessment by the Hemogram Method-Circulating Cells Complicating Reliance on Heterophil or Lymphocyte (H or L) Ratio

Original Research | Open Access | Volume 9 | Issue 1

  • 1. Cotter Laboratory, Arlington, MA, 02476, USA
+ Show More - Show Less
Corresponding Authors
Paul F. Cotter, Cotter Laboratory, Arlington, MA, 02476, 39 Hathaway Cir., USA, Tel 781 646-8976, Email: kamcotter@juno.com
ABSTRACT

The subject is a reexamination of the utility of the heterophil/lymphocyte ratio as a stress measure. The data are obtained from blood films of non-experimental chickens at 3 weeks of age and housed in isolator units. Standard differential counts of 2 x 200 cells indicated total white blood counts (TWBC) were in the range of 30-200(K) with an average of ~100(K); normal to leukemoid reaction levels (N= 23 samples). The H/L average of ~ 0.5 was typical of a non-stress hemogram. However, many atypical cells were identified including small lymphocytes with irregular cell membranes (zeiosis) reactive lymphocytes, resting (small) or activated NK (natural killer lymphocytes) unusual heterophils of three types: classic (HC), typical (HT), variant (HV), and early stages of the granulocyte series. Aggregates of atypical cells (reactive clusters) were also common. Atypia were present in blood samples at all TWBC and H/L levels. These hematological conditions suggest that estimates of stress status solely reliant on H/L data may not convey an accurate blood picture. It is necessary to integrate the calculated H/L with the TWBC and the occurrence of atypical cells to more accurately determine homeostasis.

KEYWORDS
  • Avian
  • H/L ratio
  • Stress
  • Hemogram
  • Atypical cells

 

CITATION

Cotter PF (2022) Stress Assessment by the Hemogram Method - Circulating Cells Complicating Reliance on Heterophil/Lymphocyte (H/L) Ratio. J Vet Med Res 9(1): 1224.

ABBREVIATIONS

H: heterophil (HC, classic, HV, variant, HT, typical) Ls: small lymphocyte ~6 μm diameter, Lm: medium lymphocyte, Mn: monocyte, Ba: basophil, Eo: eosinophil, TWBC (K): total white blood cells per cubic mL in thousands (K), H/L 1 = (HC + HT + HV) / Ls; H/L 2 = (HC + HT + HV) / (Ls + Lm); ΔH/L= H/L1 − H/L2, cm: cell membrane, A: area μm2

INTRODUCTION

The heterophil/lymphocyte ratio (H/L) is widely used as a technique to estimate stress [1]. Its basis is the principle that stress alters homeostasis by affecting the adrenal-corticoid axis. High glucocorticoid levels change the blood profile causing leukopenia (lymphocyte) and leukocytosis (heterophil); the H/L is raised as a consequence [2]. The data are obtained by direct hemacytometer counts, or extracted from standard differential counts (SDC) of whole blood. Automated procedures sometimes replace manual methods.

However, a number of difficulties associated with interpretation of the H/L derive from its computation, and others from the existence of cytological atypia. Few investigators describe the exact computation method used for their H/L value [3]. Should reactive lymphocytes enter the denominator? How are the several distinct heterophil types considered in determining the numerator? How do atypical cells affect the interpretation of the hemogram? [3] Is cell size considered? [4,5]. These and other questions remain unresolved. Collectively these difficulties challenge the utility of the H/L as a simple means to evaluate stress or test theories.

The purpose here is to describe cells having the potential to complicate interpretation of the avian hemogram and the derivative statistic, H/L. The focus is on cells directly entering the H/L computation, either as components of the numerator, or the denominator. An additional purpose is to illustrate examples of atypical cells, themselves an indication of a complex hemogram. Equivalents of these atypical cells are likely to occur in a broad range of species and so be of interest to a wide array of investigators.

MATERIALS AND METHODS

Animals

Chicks were obtained from an SPF flock certified free of 33 avian pathogens, Sunrise Farms, Catskill, NY 12414, USA. They were housed in Horsfall-type negative-pressure isolators. The chicks were given food, free of anticoccidials, and water ad libitum. They were examined daily and determined to be clinically healthy and sero-negative to all known chicken diseases. Wing- vein blood was drawn at 3 weeks of age, prior to the use of these animals in experiments. Additional management details are in Cotter and Heller.6

Stain Procedures

Monolayer films made by spreading approximately 3 μL of blood across alcohol cleaned glass microscope slides were air-dried and immersed in 100% MeOH. Films were stained by using an in-house version of Wright’s method followed by a brief secondary exposure to Giemsa (Sigma).

Standard Differential Count

Two counts of 200 leukocytes/slide were sorted using criteria as described by Lucas and Jamroz7 and Cotter [3,6,8]. The designation “typical heterophil” (HT) as used here was assigned to the most frequent type seen in earlier studies. Classic heterophils (HC) resemble those most often illustrated in avian hematology literature. Rare variant heterophils (HV) are distinct from both HT and HV [6,8,9]. Total white blood counts (TWBC) were determined by a modified microscopic method as described in Campbell [10]. Standard Differential Count (SDC) was determined at 40x magnification.

H/L Ratio Calculation

Division of the sum of all three heterophil types by the small “resting” lymphocytes (Ls) gives the H/L 1; [H/L 1 = (HC + HT + HV) / Ls]. Division of the same heterophil value by the sum of all lymphocyte types, (resting Ls, medium reactive (Lm) gives the H/L 2; [H/L 2 = [HC + HT + HV) /(Ls + Lm)]. ΔH/L = H/L 1 − H/L 2.

Light Microscopy and Photomicrographs

Olympus CX-41(Olympus America, Center Valley, PA 18034- 0610) equipped with Plan N 40x, 0.65 numerical aperture dry, and Plan N, 1.25 numerical aperture 100x oil objectives. All images were captured at 40x or 100x with an Infinity-2 1.4-megapixel charge-coupled device Universal Serial Bus 2.0 Camera, and processed with Infinity Analyze software (Release 5.0.3) (Lumenera, Inc., Ottawa, ON, Canada).

Graphics

Graphics were produced with Minitab Statistical Software (Release 17 for Windows, State College, PA).]

RESULTS

The SDC (%) for the samples described here is given in Table 1 along with the average for the entire flock. The scatter plot distribution for H/L 1 and H/L 2 pairs for the corresponding text figures are in Figure 1.

Figure 1 Paired scatter plot of H/L 2 vs. H/L 2 for the 7 slides providing figures, and all 23 samples (open circles) from an isolator housed 3 wk SPF flock. Reference lines indicate assumed non-stress cut-off values; H/L 1, 0.5; H/L 2, 0.4.

Figure 1 Paired scatter plot of H/L 2 vs. H/L 2 for the 7 slides providing figures, and all 23 samples (open circles) from an isolator housed 3 wk SPF flock. Reference lines indicate assumed non-stress cut-off values; H/L 1, 0.5; H/L 2, 0.4.

Table 1 indicates the TWBC for 3 samples providing the photographs were in the leukocytosis (> 50K) to leukemoid reaction (>100k) range. The corresponding H/L values were either low (samples 1,2) or in the non-stress range (samples 3,6) or stress (4,7; Table 1).

Table 1: Average of differential counts (2 x 200 cells) as a percent of TWBC and heterophil/lymphocyte ratios for text figures. H/L ratios were determined from 2 SDC counts starting at 5 and 10 mm of the microscope stage and continued until at least 200 cells were sorted. TWBC were estimated from the SDC slides.

Sample

HT

HV

HC

Ls

Lm

NK

Bst

Mn

Ba

Eo

H/L 1

H/L 2

ΔH/L

TWBC(K)

1

8.8

0.9

7.2

66.7

7.2

0.0

0.7

1.6

6.9

0.0

0.25

0.23

0.02

40

2

4.1

1.1

5.3

55.6

20.4

0.0

0.0

0.7

11.9

0.9

0.19

0.14

0.05

50

3

9.6

1.4

12.0

40.0

29.0

0.0

0.2

0.5

7.2

0.0

0.62

0.34

0.28

50

4

26.5

1.9

1.7

41.4

25.8

0.0

0.5

0.2

1.9

0.0

0.73

0.45

0.28

200

5

11.4

2.1

3.0

62.3

5.1

4.7

0.0

7.7

3.7

0.0

0.27

0.25

0.02

100

6

18.2

2.9

0.0

43.5

29.9

0.0

0.0

2.9

2.6

0.0

0.51

0.29

0.21

140

7

25.2

2.0

0.0

40.3

28.9

0.0

0.2

0.0

3.4

0.0

0.68

0.40

0.28

200

All

14.8

1.9

4.5

47.3

20.3

0.4

0.1

4.6

6.1

0.0

0.50

0.32

0.18

107

Abbreviations: H, heterophil (HC, classic, HV, variant, HT, typical) Ls small lymphocyte ~6 μm diameter, Lm medium, large (diameter 8−10 μm) NK, natural killer, Bst, granulocyte blast, Mn, monocyte including, Ba, basophil, Eo, eosinophil. TWBC (K), total white blood cells per cubic mL in thousands

(K). H/L 1 = (HC + HT + HV) / Ls; H/L 2 = (HC + HT + HV) / (Ls + Lm); ΔH/L= H/L1 − H/L2.

As indicated by Figure 1 the samples providing the photographs came from SDC’s distributed across the range of H/L values. In 3 cases (samples 3,6,7; Figure 1) duplicate SDC’s results were distinct as indicated by the separation of data points. This is caused by sorting, the non-uniform distribution of cells in reactive samples (Figure 2).

CytologResting Lymphocytes

A mixed field displaying atypia of several series is in Figure 2. Ls* are small “resting” lymphocytes with irregular cm (zeiosis, arrows). HC* is a classic heterophil with weakly stained nucleus and defective (undifferentiated) cytoplasmic granules. Medium reactive lymphocytes (Lm*) and atypical thrombocytes are present; N is the remnants of a lysed nucleus (likely a RBC).

Figure 2 A mixed field with atypia of several series. Ls* small “resting” lymphocytes with irregular cm, zeiosis (arrows). HC* classic heterophil with weakly stained nucleus and defective (undifferentiated) cytoplasmic granules. Medium reactive lymphocytes (Lm*) and atypical thrombocytes; N is the remnants of a lysed nucleus (?RBC). Collectively the Lm/Th/N/RBC aggregate is a “reactive cluster”. Additional descriptions of cells are in the text.

Figure 2 A mixed field with atypia of several series. Ls* small “resting” lymphocytes with irregular cm, zeiosis (arrows). HC* classic heterophil with weakly stained nucleus and defective (undifferentiated) cytoplasmic granules. Medium reactive lymphocytes (Lm*) and atypical thrombocytes; N is the remnants of a lysed nucleus (?RBC). Collectively the Lm/Th/N/RBC aggregate is a “reactive cluster”. Additional descriptions of cells are in the text.

Reactive Lymphocytes

Reactive lymphocytes (Lm, Figure 3, Panel A) are rarely seen in normal hemograms. These moderately sized cells (Lm 1, A 50 μm2 and Lm 2, A 36 μm2) are noticeably larger than the nearby resting lymphocyte (Ls, A 12 μm2). The lower Lm N/C ratios (~ 0.7) contrast with the Ls (N/C ~ 0.9) and so these are likely developmental plasmacytes. When granulated lymphocytes (NK cells; Panels B and C, Figure 3) appear in a hemogram a further difficulty arises. These cells can indicate an active (anti-viral) immune response is already in progress [11]. Furthermore, developmental cells of the granulocyte series, themselves an indication of inflammation, can be mistaken for NK cells (Figure 3, Panel D).

Figure 3 Panel A. Reactive lymphocytes (Lm) are differentiated form small resting lymphocytes (Ls). Panels B-D. NK (natural killer) lymphocytes contain cytoplasmic granules (arrow Panel B) and can resemble cells of the granulocytic series (mesomyelocyte, msm, Panel D). Bar 10?m. Additional descriptions of cells are in the text.

Figure 3 Panel A. Reactive lymphocytes (Lm) are differentiated form small resting lymphocytes (Ls). Panels B-D. NK (natural killer) lymphocytes contain cytoplasmic granules (arrow Panel B) and can resemble cells of the granulocytic series (mesomyelocyte, msm, Panel D). Bar 10μm. Additional descriptions of cells are in the text.

Heterophil Granulocytes

Traditionally placement of avian granulocytes is into one of three groups, heterophil, basophil, or eosinophil [7,10]. The cytoplasmic granules of chicken heterophils and eosinophils are red but shaped differently. The fusiform (spindle) shape of heterophil granules aids their differentiation from eosinophils whose granules are spherical. Granule stain intensity, the central bodies of classic heterophils (HC) and variation of nuclear configuration are additional distinctions among heterophil types. Basophils are also granulocytes whose deep purple metachromatic spheres allow easy differentiation from other granulocytes. All granulocytes develop from a common stem cell, but mature cells descend from distinct metamyelocyte progenitors [7]. Heterophils are not a single series. Three distinct types (typical, HT; classic HC, and variant, HV) differentiated by granulation and nuclear configuration have been described [5,6,9]. HT types, often the most frequent, bear some resemblance to mammalian neutrophils (Figure 4).

Figure 4 Examples of standard sized (R ~5 ?m; A ~ 80 ?m2) classic (HC) typical (HT) and variant heterophils (HV) from a 6 wk SPF chick. Classification is based on cytoplasmic granulation and nuclear configuration differences. Additional descriptions of cells are in the text.

Figure 4 Examples of standard sized (R ~5 μm; A ~ 80 μm2) classic (HC) typical (HT) and variant heterophils (HV) from a 6 wk SPF chick. Classification is based on cytoplasmic granulation and nuclear configuration differences. Additional descriptions of cells are in the text.

Further examples of HV and HC differentiation are given in Figure 5. Panel A. Standard sized classic heterophil (HC, A 58 μm2) is compared with medium sized variant types (HV 1 and 2; A ~ 48 μm2) and atypical small lymphocytes Ls (1, 3). The HC granules are poorly stained in contrast with those of the HV. This indicates an HC granulation defect rather than a staining artifact. A true “resting” Ls (2) N/C ~1, is also in the same field. Panel B. A large HV (A 85 μm2) and a medium lymphocyte are in transition to the reactive state (Ls/Lm, A 55 μm2). The cytoplasmic granules of the HV are orange spheres, distinct form the red spheres of eosinophils, and are often restricted to one side of the nucleus. The HV in panel B has fewer cytoplasmic granules than are ordinarily found. Thrombocyte (Th) shape and size irregularities, indicating they are reactive, are seen in both panels (Figure 5,6).

Figure 5 Further examples of variant heterophils (HV) and reactive/atypical lymphocytes. Panel A. Standard sized classic heterophil compared with medium sized and atypical (zeiosis) Ls (1, 3). Panel B. Large HV (A 85 ?m2) and medium lymphocyte in transition to the reactive state (Ls/Lm, A 55 ?m2). Thrombocytes (Th) are in both panels. Bar 10 ?m.

Figure 5 Further examples of variant heterophils (HV) and reactive/atypical lymphocytes. Panel A. Standard sized classic heterophil compared with medium sized and atypical (zeiosis) Ls (1, 3). Panel B. Large HV (A 85 μm2) and medium lymphocyte in transition to the reactive state (Ls/Lm, A 55 μm2). Thrombocytes (Th) are in both panels. Bar 10 μm.

Figure 6 Granule number deficiency in heterophils. Examples of standard sized (Ave. area 88 ?m2) variant heterophils (HV) with apparent deficiency of cytoplasmic granules. An HV with a full complement of cytoplasmic granules is in the inset of panel B.

Figure 6 Granule number deficiency in heterophils. Examples of standard sized (Ave. area 88 μm2) variant heterophils (HV) with apparent deficiency of cytoplasmic granules. An HV with a full complement of cytoplasmic granules is in the inset of panel B.

 

EOSINOPHILS

Eosinophils (Figure 7) are sometimes mistaken for classic heterophils. A late eosinophilic metamyelocyte (mtm) has a non- segmented nucleus with coarsely condensed chromatin and red spherical cytoplasmic granules (A 38 μm2); a necrotic heterophil (HC or HT) is at the top right. Panels B, C, and D contain additional examples of mature (2 nuclear lobes; A ~39 μm2) Eo. A faint pseudopod projects from the Eo of panel D (arrow). Eosinophils are differentiated from HV type heterophils by their red cytoplasmic granules and smaller sizes (Figure 7).

Figure 7 Panel A. A late eosinophilic metamyelocyte (mtm) chromatin and red spherical cytoplasmic granules (A 38 ?m2); a necrotic heterophil (HC or HT) is at the top right. Panels B, C, and D contain additional examples of mature (2 nuclear lobes; A ~39 ?m2) Eo. Additional descriptions of cells are in the text.

Figure 7 Panel A. A late eosinophilic metamyelocyte (mtm) chromatin and red spherical cytoplasmic granules (A 38 μm2); a necrotic heterophil (HC or HT) is at the top right. Panels B, C, and D contain additional examples of mature (2 nuclear lobes; A ~39 μm2) Eo. Additional descriptions of cells are in the text.

DISCUSSION

The objective of this manuscript is to describe circumstances where determination of stress by the H/L method is not a straight forward process. This arises because often no careful description of the method used to calculate the H/L is provided. This deficiency can render data comparisons between studies and tests of theories problematic. No statistical transformation technique (see Valdebenito [12] for an example) can overcome such difficulties.

Furthermore, the inclusion of reactive cells is rarely declared. Nor are cut-off values separating stress from non-stress firmly established. Recognition of atypia is important. Toxic and apoptotic heterophils are potentially injurious and thus should not be found in a normal (non-stress) hemogram [13].

Small “resting” lymphocytes can be problematic if they are atypical. The Ls* of Figure 1 are an example of cells whose surrounding membranes have developed projections (blebs) often considered as zeiosis, a prodromal stage of apoptosis (programmed death).

Heterophils, the H of the H/L are diverse, differing in granulation and nuclear condition, justifying the separate categories (HC, HT, and HV). Moreover, toxic and other forms of atypia as giant cells, and dwarfs, can occur among any H type adding another level of complication [4].

The present study is limited because physiologic differences of granules among heterophils types have not yet been established. It may be that either HT or HV are capable of myeloperoxidase production, a property not in HC [14] Furthermore, the differential phagocytic capacity of each heterophil type is not known, nor is type-specific toxicity differences of necrotic heterophils. However, recognition of subtle toxic changes has been ignored (see Figure 1 of Davis [1] for an example).

Recently an apparent novel type of apoptosis occurring in HC types has been described [8]. Whether this process is restricted to the HC type or can occur in HT and HV is not yet known. It may account for some H/L variation if HC types are underrepresented in the SDC; because of lysis an artificially low value could result.

NK cells were found in a minority 3/23 (13%) of samples and were between 1 and 5% of the SDC. Some NK with only a few cytoplasmic granules cells were probably the resting type; others with more granules are probably the reactive type suggesting viral infection [15].

In summary, some weaknesses of the H/L method earlier described have been extended by the present observations [3,5]. These include how the H/L is actually calculated and the effect of atypical cells [9].

CONCLUSION

The data presented here expand upon an earlier study examining the utility of the H/L ratio as a stress measure [3]. Atypical cells of that study were seen in blood films from hens in several types of commercial cages. Those hens were sampled between 18 and 77 wk. Here younger chickens (3 wk) housed in isolators, and free of known disease, are the subject. Interestingly the isolator samples contained many atypical and reactive cells. NK cells, for example, are indicators of viral infection; atypical heterophils are common in blood also containing bacteria [9]. It is likely that in the present study microbial contaminants of blood came from the gut. The results show that in the presence of atypia, as described here, the use of a simple H/L ratio fails to establish stress status.

These data are intended to draw attention to the need for consensus among investigators who use the H/L method in their choice of cells included in its computation. Atypical or reactive lymphocytes should not be included in the denominator. The choice of heterophils is also important. As it is not currently known if HT and HV types are physiologically distinct from the better-known HC; either may indicate a complex hemogram. Moreover, low H/L ratios in samples with high TWBC cannot be interpreted as non-stress. The question of leukopenia has not been adequately addressed. Finally, caution must be given to samples with atypical cells of the other series not directly used for the H/L.

ACKNOWLEDGEMENTS

The author is grateful to Dr. E. D. Heller, Hebrew University of Jerusalem, Faculty of Agriculture, who prepared the slides.

REFERENCES
  1. Davis AK, Maney DL, Maerz JC. The use of leukocyte profiles to measure stress in vertebrates: a review for ecologists. 2008.
  2. Scanes CG. Biology of stress in poultry with emphasis on glucocorticoids and the heterophil to lymphocyte ratio. Poultry Science. 2016; 95: 2208-2215.
  3. Cotter PF. An examination of the utility of heterophil -lymphocyte ratios in assessing stress of caged hens. Poultry Science. 2015; 94: 512–517.
  4. Cotter PF, C Buckley. Giant cells and plasmacyte atypia of duck blood (frank indicators of immunosuppression). Proc. 67th Western Poultry Disease Conf. 2018.
  5. Cotter PF. Atypical lymphocytes and leukocytes in the peripheral circulation of caged hens. Poultry Science. 2015; 94: 1439–1445.
  6. Cotter PF, ED Heller. Complex Hemograms of Isolator Raised Specific Pathogen Free (SPF) Chicks. International Journal of Poultry Science. 2016; 15: 211-217.
  7. Lucas AM, C Jamroz. Atlas of Avian Hematology, Monograph 25, USDA, Washington, DC. 1961.
  8. Cotter PF. Atypical hemograms of the commercial duck. Poult Sci. 2021; 100: 101248.
  9. Cotter PF. Apoptosis of Circulating Heterophils; Implications for the Interpretation the Heterophil/Lymphocyte Ratio. J Immunological Sci. 2021; 5: 1-8.
  10. Campbell TW, CK Ellis. Avian and Exotic Animal Hematology and Cytology. 3rd edn. Blackwell Publ., Ames, IA. 2007.
  11. Mostafa Abdolmaleki, Swee Keong Yeap, Sheau Wei Tan, Dilan Amila Satharasinghe, Muhammad Bashir Bello, Mohammad Zareian Jahromi, et al. 2018. Effects of newcastle disease virus infection on chicken intestinal intraepithelial natural killer cells. Frontiers in immunology. 2018; 9: 1386.
  12. José O Valdebenito, Naerhulan Halimubieke, Ádám Z Lendvai, Jordi Figuerola, Götz Eichhorn, Tamás Székely. Seasonal variation in sex- specific immunity in wild birds. Sci Rep. 2021; 11: 1349.
  13. Viktoria Rungelrath, Scott D Kobayashi, Frank R DeLeo. Neutrophils in innate immunity and systems biology-level approaches. Wiley Interdiscip Rev Syst Biol Med. 2020; 12: e1458.
  14. R Penniall, JK Spitznagel. Chicken neutrophils: oxidative metabolism in phagocytic cells devoid of myeloperoxidase. Proc Natl Acad Sci U S A. 1975; 72: 5012-5015.
  15. Christine A Jansen, Eveline D de Geus, Daphne A van Haarlem, Peter M van de Haar, Brandon Z Löndt, Simon P Graham, et al.. Differential lung NK cell responses in avian influenza virus infected chickens correlate with pathogenicity. Sci Rep. 2013; 3: 2478.

 

Cotter PF (2022) Stress Assessment by the Hemogram Method - Circulating Cells Complicating Reliance on Heterophil/Lymphocyte (H/L) Ratio. J Vet Med Res 9(1): 1224.

Received : 25 Feb 2022
Accepted : 29 Mar 2022
Published : 31 Mar 2022
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
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
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