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

Users Online : 68155

AbstractMaterial and MethodsResultsDiscussionConclusionKey MessageReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"

Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."

Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

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 : 2011 | Month : November | Volume : 5 | Issue : 7 | Page : 1389 - 1392 Full Version

A study on the blood levels of homocysteine, fibrinogen and hsCRP in diabetic patients with ischaemic stroke from eastern India

Published: November 1, 2011 | DOI:
Rudrajit Paul, Pradip K Sinha, Avishek Saha, Ramtanu Bandyopadhyay, Amit K Banerjee

1. Corresponding Author 2. MD, DM, Associate Professor, Department of Medicine, Medical College Kolkata, Kolkata, West Bengal, India. 3. MD, RMO, Department of Medicine, Medical College Kolkata, Kolkata, West Bengal, India. 4. MD, Associate Professor, Department of Medicine, Medical College Kolkata, Kolkata, West Bengal, India. 5. MD, Professor and Head, Department of Medicine, Medical College Kolkata, Kolkata, West Bengal, India.

Correspondence Address :
Rudrajit Paul
Junior Resident, Department of Medicine,
Medical College Kolkata
15/5, Bose Pukur Road, Kolkata-700 039. West Bengal
Phone : 91-9433824341
E-mail :


Introduction: Diabetes is an important risk factor for ischaemic stroke. Newer risk markers like C - reactive protein, fibrinogen and homocysteine levels are now being considered for better risk predication.

Aim: To study these new risk markers in diabetic patients with ischaemic stroke and to study any association of these markers with other blood parameters. This was thus a case control study.

Methods: Patients who were proved (by imaging) to be suffering from cerebral ischaemic events were chosen after proper screening and after their consent was taken. The diabetic subset was compared with the non-diabetic subset by doing blood tests which included blood glucose, lipids and newer markers. This was done 2 months after the index event to avoid false positive results.

Statistical analysis: We analyzed the data by using online software. Pearson’s correlation coefficient was used for finding the correlation between the variables.

Results: 82 patients were included in the study, of which 42 were diabetic (ADA Criteria). The diabetic subset had significantly higher levels of total serum cholesterol (186 ± 50.3 vs. 167± 30.6; p=0.041) and LDL levels (112 ± 33.3 vs. 92± 15.2; p=0.0008). The triglyceride levels were also higher (165± 19.35 vs. 124.6± 9.22; p=0.0010). The HsCRP and fibrinogen levels were higher in diabetic patients with ischaemic stroke (p<0.05), while the homocysteine levels were higher in the non-diabetic subsets. The high hsCRP levels also correlated significantly with blood glucose (for FBS; r= 0.288; for PPBS, r=0.407) and blood pressure. There was also a positive correlation between hsCRP and the fibrinogen levels (r=0.307; p<0.05). The ROC curve analysis showed that LDL values which were >110 mg/dl had a high sensitivity in predicting high levels of plasma homocysteine. The logistic regression model showed that hsCRP had the strongest correlation with increasing age (OR=1.1).

Conclusion: This case control study has shown significantly higher hsCRP and fibrinogen levels in ischaemic stroke patients who had diabetes, as compared to the non-diabetic subsets. These newer parameters were also correlated with blood glucose and the lipid values. Thus, these can be used as surrogate markers in diabetic patients for the prediction of ischaemic stroke. However, a prospective study is needed to identify the risk factors and their predicative value better.


hsCRP, homocysteine, fibrinogen, stroke, diabetes, blood glucose.

Diabetes is a significant risk factor for ischaemic stroke, particularly in the young (1),(2). Associated factors like hypertension and dyslipidaemia predispose to stroke in a synergistic way with hyperglycaemia (1). A study from south India has shown that diabetes as a risk factor has an odds ratio of 4.55 for causing ischaemic stroke (2).

Now, some newer risk factors are also being considered to be important in the pathophysiology of the vascular events. Plasma homocysteine levels are considered to be a vascular risk factor which is independent of hyperglycaemia (3). Homocysteine is implicated in both coronary and cerebrovascular events, particularly in association with hypertension (4). The plasma levels of another marker, fibrinogen correlate with the parameters of thrombin activation (5). The fibrinogen levels also correlative positively with hypertension and cholesterol levels (6). Including the C - reactive protein (CRP) for the risk assessment of cardiovascular events in diabetes gives a better predicative value (7). CRP is a marker of endothelial activation and inflammation (8),(9).

Thus, the measurement of these novel risk factors can be a new method to predict the risk in diabetes.

This study was conducted to assess the effect of homocysteine, fibrinogen and hsCRP levels along with other risk factors for atherosclerosis, in diabetic patients with ischaemic stroke and to compare these values with the values in non-diabetic patients with ischaemic stroke.

Material and Methods

We selected 82 patients of ischaemic stroke (proved by CT scan and/or MRI brain), who were admitted to the Department ofMedicine over a period of one year, from 30th November, 2009 to 31st October, 2010. The patients were divided into two groups: diabetic and non-diabetic. Only the patients whose ischaemic stroke was proved by CT scan or MRI of the brain were included in this study. Patients with suspected infection, HIV and rheumatological disorders like SLE, those who were on steroids and those who had known clotting disorder, overt signs of vitamin deficiency or malnutrition or pregnancy were excluded from our study.

After a proper clinical examination and after checking the past treatment records, the patients were subjected to laboratory tests like complete blood count, estimation of fasting and two hour post prandial blood glucose levels (measured by the glucose oxidase method), HbA1C% (determined by electrophoresis), blood lipid levels i.e. cholesterol, LDL, HDL and triglycerides (LDL was estimated by the cholesterol oxidase method, triglycerides by the glycerol peroxidase method and HDL by the PEG precipitation method ), routine urine examination and ECG. The blood glucose and lipid levels were measured within 12 hours of the event, or after 4 weeks. The homocysteine, fibrinogen and hsCRP levels were also measured in all the patients. The fibrinogen levels (Normal range: 200-400 mg/dl) were measured by using Beckman Coulter Synchron CX5 pro, USA. The HsCRP levels were measured by an immuno-turbidimetic method and the cut off value of hsCRP was chosen as 3 mg/L, as the values above this were found to confer an increased vascular risk. The homocysteine levels (normal values were taken here as <15 micromole/L) were measured in the fasting state, as homocysteine was observed to stay relatively constant over time for individuals who were in a stable state of health without dietary changes and as a protein rich meal could induce increases in the homocysteine levels for the next several hours.

These measurements were done at least 2 months after the event to avoid falsely elevated values in the acute phase. Diabetes was diagnosed according to the American Diabetes Association’s guideline, 2010 (10).

However, reactive hyperglycaemia was not considered. For this, any high blood glucose value (except Hb A1C) was rechecked at least 5 days after the event to confirm the diabetic status. Also, the past records of the diabetics were considered.

The data was arranged in a Microsoft Excel worksheet. The analysis was done by using software like MedCalc, Graphpad and epiInfo, which were downloadable from the internet. The Student’s t test was used to find the significant difference among the continuous variables between the 2 groups. The categorical data was arranged in 2*2 contingency tables and these were analyzed by using Chi square tests.

P-values which were less than 0.05 were considered to be significant.


There was a total of 82 patients of ischaemic stroke in our study, with a sex ratio of 50 males: 32 females. Forty two patients were diagnosed to be diabetic according to American Diabetic Association (ADA) criteria as per the blood test results (11). The average age of the study population was 62.3 ± 9.75 years. (Table/Fig 1) shows the comparison of the various parameters in between the two groups. It was seen that the diabetic subset had significantly higher levels of total serum cholesterol (186 ± 50.3 vs. 167± 30.6; p=0.041) and LDL levels (112 ± 33.3 vs. 92± 15.2; p=0.0008). The triglyceride levels were also higher (165± 19.35 vs. 124.6±9.22; p=0.0010). The systolic blood pressure was also higher in diabetics, but the difference were not significant (p=0.48).

The study parameters in the two groups are shown in (Table/Fig 2). It was seen that in the diabetic subset, the hsCRP and the fibrinogen levels are significantly higher, while the homocysteine levels were significantly higher in the non-diabetic subset (12.5 ± 3.25 vs. 21.1 ± 9.65; p<0.0001). In (Table/Fig 3), the correlation of the hsCRP, fibrinogen and the homocysteine levels have been made with the other conventional risk factors among all the patients who were included in the study. The correlation study of hsCRP, fibrinogen and homocysteine showed that blood glucose had a strong correlation with these parameters. While for hsCRP and fibrinogen, the correlation was positive, for the homocysteine levels, this was not seen. This correlation was shown for both the FBS and the PPBS levels in the variables. The blood lipid levels correlated with the homocysteine values only (for total cholesterol, r=0.34, for LDL, r=0.45). The blood pressure, especially the systolic pressure (SBP) showed a positive correlation with the hsCRP and the fibrinogen levels (for hsCRP, r=0.21; for fibrinogen, r=0.24 for SBP). The ages of the patients were also correlated with the hsCRP(r=0.27) and the fibrinogen (r=0.215) levels. BMI (Body mass Index) did not show any significant association. These values resulted from the independent analysis of each variable. When the logistic regression model was used, the odds ratio for the high fibrinogen levels was 1.03 for high PPBS and it was 1.07 for the older age patients (p=0.0036). For the homocysteine levels, the odds ratio for LDL was 1.02 (p<0.0001). For the hsCRP levels, the odds ratio in case of age was the strongest (OR=1.102; p<0.0001), while for PPBS, it was 1.02. By using the ROC curve analysis (Table/Fig 5), it was found that age which was >59 years had a sensitivity of 93% in predicting high CRP levels; however, the specificity was only 43% (p=0.008). A similar ROC curve analysis (Table/Fig 6) also showed that LDL values which were >110 mg/dl had a specificity of 94% in predicting the high homocysteine levels (p<0.0001). The correlation data between the 3 study variables showed that (Table/Fig 4), there was a positive correlation between hsCRP and fibrinogen (r=0.307), while for homocysteine, the correlation was negative (r=- 0.302; p=0.0058). This negative correlation of homocysteine was also seen with fibrinogen, although the correlation was less strong (r=0.25).


In our cross sectional study, we studied the different blood parameters in patients of ischaemic stroke and compared the results between the diabetic and the non-diabetic population. We found significantly higher levels of cholesterol, LDL and triglycerides in the diabetic population; also, the levels of hsCRP and fibrinogen were significantly higher. However, the serum homocysteine levels were significantly higher in the non-diabetic sub-group. These three vascular risk markers, hsCRP, fibrinogen and homocysteine showed a significant correlation with factors like age, pressure and blood sugar. Also, there was a positive correlation between the hsCRP and the fibrinogen levels.

Diabetes has been proved to be a great risk factor for stroke in all the age groups (1),(2). In a study from West Bengal, it was seen that hypertension with diabetes was significantly related to ischaemic stroke (11).

The novel risk factors hsCRP, fibrinogen and homocysteine are gaining importance as the predictors of vascular events beyond the blood glucose levels. Especially, the hsCRP levels have been shown to be the markers of atherosclerosis in different studies (8). In our study, we found significantly high levels of hsCRP (3.29± 2.28 mg/L) in the diabetic subset. In different studies, it was shown that hsCRP was independently associated with stroke or other vascular events over a 7 year follow up (7). The HsCRP levels in the presence of diabetes has an even greater significance (8),(9).

Fibrinogen is also a marker of altered vascular physiology in diabetes (6). A study from Italy showed that diabetic subsets had increased levels of fibrinogen and that it correlated with the HbA1c levels (6). In our study, we did not find this correlation, probably due to the small number of subjects. The fibrinogen levels were also found to correlate with a higher risk of ischaemic stroke, which was independent of the blood glucose levels (12). In the same study, hsCRP was found to be an important prognostic factor, not just a risk marker (12). The CRP levels could identify those patients whose inflammation system responded most actively to stimuli (12).

In our study, we found lower levels of homocysteine in the diabetic subsets (12.5 ± 3.25 vs. 21.1 ± 9.65; p<0.0001). The correlation of diabetes and homocysteine has been debated. In some studies, the homocysteine levels in diabetic patients have been found to predict cardiovascular events strongly (4). However, other studies have shown low homocysteine levels in the diabetic populations, especially in the young, type 1 diabetics (13). The levels of homocysteine in diabetics are also influenced by their insulin concentrations, the therapy with insulin, and medications such as metformin and glitazones that can either raise or lower the homocysteine levels (14). In animal experiments, the plasma homocysteine levels were reduced in streptozotocin-induced diabetic rats and they were increased with the institution of insulin treatment (15).

Plasma homocysteine is now known to be an important vascular risk factor (4). In our study, we found a significant correlation of homocysteine with blood lipid levels (for cholesterol, r=0.34; for LDL r=0.45; p<0.05). This correlation, esp. with LDL was also shown in other studies (16).

HsCRP levels are directly related to insulin resistance. This was reflected in the significant positive correlation of CRP with fasting and post-prandial blood sugar levels in our study (for FBS; r= 0.288; for PPBS, r=0.407). This correlation of CRP with insulin resistance and other components of the metabolic syndrome werealso documented in other studies (7). Another study from Germany has shown the correlation of factors like age, blood glucose and blood lipids with CRP and fibrinogen (17). In our study, age was correlated to the fibrinogen levels, with a marginal statistical significance (p=0.051).

Blood pressure was also correlated to these new risk markers. Especially, with CRP, this correlation was very strong (18). In our study, hsCRP was significantly correlated only to SBP (r=0.21), but its correlation with SBP, DBP and pulse pressure all are known (18). Fibrinogen was also elevated significantly with respect to blood pressure in our study (for SBP, r=0.24; for DBP, r=0.278; p<0.05). Different studies have also found this link between hypertension and the fibrinogen levels, which is probably due to increased viscosity (19).

Since our study was cross sectional, it was limited in its ability to find out the relative importance of the above factors in risk stratification. For that, prospective studies with a relatively larger patient population are needed.


In this study, the diabetic patients with ischaemic stroke were found to have significantly higher levels of hsCRP and fibrinogen. These variables also correlated significantly with the vascular risk markers like age, blood pressure and blood glucose. For homocysteine, the non-diabetic subset was found to have a higher level. The actual impact of these newer risk factors needs to be assessed by doing larger prospective studies. However, this study shows that these newer risk factors can be measured in diabetic patients for a better risk prediction. Also, the need for better blood pressure and blood sugar control has to be emphasized. Plasma homocysteine may be an independent risk factor in non-diabetic ischaemic stroke patients and its measurement as a screening test needs further studies.

Key Message

A proinflammatory state in diabetes predisposes to vascular events like stroke. The estimation of these new risk factors can help in better risk prediction in diabetic patients.


Folsom AR, Rasmussen ML, Chambless LE, Howard G, Cooper LS, Schmidt MI et al. Prospective associations of fasting insulin, body fat distribution, and diabetes with the risk of ischemic stroke. The Atherosclerosis Risk in Communities (ARIC) Study Investigators. Diabetes Care. 1999; 22: 1077-83.
Lipska K, Sylaja PN, Sarma PS, Thankappan KR, Kutty VR, Vasan RS et al. Risk factors for acute ischaemic stroke in young adults in South India. J Neurol Neurosurg Psychiatry. 2007; 78:959-63.
Soinio M, Marniemi J, Laakso M, Lehto S, Rönnemaa T. Elevatedplasma homocysteine levels is an independent predictor of coronary heart disease events in patients with type 2 diabetes mellitus. Ann Intern Med. 2004; 140:94-100.
Bots ML, Launer LJ, Lindemans J, Hoes AW, Hofman A, Witteman JC, et al. Homocysteine and short-term risk of myocardial infarction and stroke in the elderly: the Rotterdam Study. Arch Intern Med. 1999; 159:38-44.
Ceriello A, Taboga C, Giacomello R, Falleti E, De Stasio G, Motz E, et al. Fibrinogen plasma levels as a marker of thrombin activation in diabetes. Diabetes. 1994; 43:430-2.
Haffner SM. The metabolic syndrome: inflammation, diabetes mellitus, and cardiovascular disease. Am J Cardiol. 2006; 97:3A-11A.
Soinio M, Marniemi J, Laakso M, Lehto S, Rönnemaa T. Highsensitivity C-reactive protein and coronary heart disease mortality in patients with type 2 diabetes: a 7-year follow-up study. Diabetes Care. 2006; 29(2):329-33.
Ridker PM. Inflammatory biomarkers and risks of myocardial infarction, stroke, diabetes, and total mortality: implications for longevity. Nutr Rev. 2007; 65(12 Pt 2):S253-9.
Theuma P, Fonseca VA. Inflammation and emerging risk factors in diabetes mellitus and atherosclerosis. Curr Diab Rep. 2003; 3:248-54.
American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2010; 33 Suppl 1:S62-9.
Banerjee TK, Das SK. Epidemiology of stroke in India. Neurology Asia 2006; 11 : 1 – 4
Di Napoli M, Papa F, Bocola V. Prognostic influence of increased C-reactive protein and fibrinogen levels in ischaemic stroke. Stroke. 2001; 32:133-8.
Cotellessa M, Minniti G, Cerone R, Prigione F, Calevo MG, Lorini R, et al. Low total plasma homocysteine concentrations in patients with type 1 diabetes. Diabetes Care. 2001; 24:969-71.
Elias AN, Eng S. Homocysteine concentrations in patients with diabetes mellitus – relationship to microvascular and macrovascular disease. Diabetes, Obesity and Metabolism 2005; 7; 117–21.
Jacobs RL, House JD, Brosnan ME, Brosnan JT. Effects of streptozotocin-induced diabetes and of insulin treatment on homocysteine metabolism in the rat. Diabetes. 1998; 47: 1967–70.
Herrmann W, Obeid R, HĂĽbner U, Jouma M, Geisel J. Homocysteine in relation to C-reactive protein and low-density lipoprotein cholesterol in the assessment of cardiovascular risk. Cell Mol Biol (Noisy-le-grand). 2004; 50:895-901.
Grau AJ, Buggle F, Becher H, Werle E, Hacke W. The association of leukocyte count, fibrinogen and C-reactive protein with vascular risk factors and ischaemic vascular diseases. Thromb Res. 1996; 82:245- 55.
Smith DG, Lawlor DA, Harbord R, Timpson N, Rumley A, Lowe GD et al. Association of C-reactive protein with blood pressure and hypertension: life course confounding and mendelian randomization tests of causality. Arterioscler Thromb Vasc Biol. 2005 ;25:1051-6
Letcher RL, Chien S, Pickering TG, Sealey JE, Laragh JH. Direct relationship between blood pressure and blood viscosity in normal and hypertensive subjects. Role of fibrinogen and concentration. Am J Med. 1981; 70:1195-202.

DOI and Others


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