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

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On Sep 2018

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"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."

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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.
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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

Important Notice

Original article / research
Year : 2011 | Month : October | Volume : 5 | Issue : 5 | Page : 1051 - 1055

Daytime Sleepiness and Quality of Sleep in Punjabi Diabetic Population

Upneet Bedi, Gaurav Mittal, Rajiv Arora

1.Corresponding Author. 2. Punjab Institute of Medical Sciences, Jalandhar, Punjab, India. 3. Punjab Institute of Medical Sciences, Jalandhar, Punjab, India.

Correspondence Address :
Upneet Bedi, Assistant Professor,
Department of Physiology,
Punjab Institute of Medical Sciences,
Jalandhar, Punjab, India.
Phone: 9814814811


The study was carried out at the medicine outpatient department of Punjab Institute of Medical Sciences Hospital and Medical College Jalandhar to examine the daytime sleepiness and quality of sleep in diabetic population sample. A total number of 201 T2DM patients aged above 20 years of age were taken. The study included information about socio-demographic characteristics including age, sex, income, education level, occupation, and other parameters like height, weight, BP, fasting blood sugar, lipid profile and physical activity and sleeping habits during the past month. Epworth sleepiness score (ESS) and the Pittsburgh sleep quality index (PSQI) have been used to study sleep quality and daytime sleepiness. Chi-square tests were performed to test for differences in proportions of categorical variables between two or more groups. The level p<0.05 was considered as the cut- off value for significance. Of the studied diabetic patients 101 were males and 100 were females. Comparison of sleeping quality using Epworth sleepiness scale(ESS) showed that female diabetic patients had significantly high chances of falling asleep during the day time than men; in terms of watching TV (p = 0.00008), passenger in car (p = 0.0001), lying down to rest in afternoon (p = 0.019), sitting & talking (p = 0.027) and car stopped in traffic (p = 0.00001). However, there existed an insignificant difference between males & females in terms of falling asleep during day while sitting and reading (p = 0.206), sitting inactive in public place (p = 0.109), sitting quietly after lunch (p = 0.28) and ESS score results (p = 0.245) Overall 35% of the diabetic patients were very sleepy during the daytime with 49% men and 50% women. Obesity was significantly higher in diabetic women who had higher chances of daytime sleepiness than men (p = 0.00005). Physical activity was significantly lower in diabetic women with poor sleep compared to men (p = 0.001). This study finding showed that sleep quality was bad in diabetic population and also day time sleepiness was observed in diabetic population.


Diabetes, Daytime sleepiness, PSQI, ESS

Diabetes is a chronic disease that is becoming more and more prevalent in our society. Poor diet, refined and processed foods, a sedentary lifestyle and a worldwide epidemic of obesity are contributing to the rapidly rising numbers of the disease. According to the World Health Organization (WHO), approximately 150 million people worldwide have diabetes. There is an increasing concern about the effect metabolic disorders, especially diabetes have on health services (1).

Sleep disorders were commonly found in patients with type-2 diabetes (2). When compared with non-diabetics, patients with diabetes report higher rates of insomnia, excessive daytime sleepiness, and unpleasant sensations in the legs that disturb sleep (2),(3). Therefore, it is not surprising that up to 71% of diabetic population complain of poor sleep quality (4) and high rates of hypnotic use (3). Chronic sleep loss is associated with the endemic condition of diabetes in our society, and affects about 45% of all adults.

Multiple factors contribute to insomnia complaints in patients with diabetes like rapid changes in glucose levels during sleep, obesityassociated sleep disorders, discomfort or pain associated with peripheral neuropathy (5). Because the aetiology of poor sleep quality is often multifactorial and may shift over time, a careful evaluation for insomnia, sleep-disordered breathing, and restless legs syndrome should be an integral part of the routine care of patients with diabetes because improving sleep and treatment of sleep disorders can improve glucose control, health, and quality of life.

In a prospective population study of female participants, poor sleep quality was reported by those who had diabetes compared to those who did not (6), and sleep duration and quality were shown to be significant predictors of glycemic control in a cross-sectional study of volunteers with type II diabetes (7). In a study that was conducted on 220 type-2 diabetics, it was concluded that of type-2 diabetics had reduced sleep and that there is a definite association between blood sugar control and the quality and quantity of sleep (8).

The state of Punjab is a rapidly developing with a change that influenced the lifestyle of the people towards urbanization. As our knowledge goes no study has been conducted to examine the excessive daytime sleepiness and quality of sleep in Punjabi diabetic population. The existence of sleep loss in type-2 DM population is important to study because not only do these 2 chronic disorders co-exist but there is also growing evidence that they exacerbate each other.

Hence this study was aimed to examine the daytime sleepiness and quality of sleep in diabetic Punjabi population residing in Punjab state.

Material and Methods

This study was conducted among the adult Punjabi population above 20 years of age residing in state of Punjab. The study was approved by the institutional ethics committee of PIMS. A total no of 201 T2DM patients of which 101 were males and 100 were females were selected from the medicine OPD of Punjab Institute of Medical Sciences Hospital and Medical College, JalandharPunjab. Each participant was provided with brief information about the study and was assured of strict confidentiality and a informed consent was taken from the subjects.

A well designed questionnaire was used to collect the data. The first part included information about socio-demographic characteristics including age, sex, education level, occupation, height, weight. The second section collected information about medical history, smoking habit and physical activity. The third section included items about sleeping habits during the past month and the Epworth sleepiness scale (ESS) score (9) The Epworth sleepiness scale is a simple and reliable measure used to assess the likelihood that an individual will fall asleep in a series of situations such as watching TV, sitting and reading, sitting in a car etc. The scoring of the answers is 0-3, with 0 being “would never doze”, 1 for “slight chance of dozing”, 2 for “moderate chance of dozing” and 3 high chance of dozing. A score lower than 6 signifies as getting enough sleep, 7-8 as tends to be sleepy and greater than 9 as very sleepy and they require medical advice. Pittsburgh sleep quality index PSQI (10) was used to check the sleep habits of diabetic patients. For each of the questions of the questionnaire, reply was classified as “not during the last month”, less than once a week “Once or twice a week” and “three or more times a week”.

Selection of type-2 Diabetic (T2DM Subjects)
Subjects with history of T2DM and currently taking oral medications for diabetes were considered to have Diabetes Mellitus. T2DM was defined according to the WHO expert group that is fasting venous blood glucose concentration>7.0mmol/l. A total number of 201 T2DM patients aged above 20 years of age were selected from medicine OPD. These patients were interviewed and questionnaire was completed. Physical examination and measurements were performed by a trained nurse. Height was measured in centimeters. Weight was measured in kilograms. The subjects were asked to stand on the weight scale bare feet with light clothing. BMI was calculated as the ratio of weight (kilogram) to the square of height (meters). Obesity and overweight were classified according to WHO criteria (10), (11). A person was considered obese if the BMI value was > 30kg/m2, overweight if BMI was (25-30kg/m2)

Blood pressure measurement was carried out by Nurse according to standardized criteria. Blood pressure was recorded to the nearest millimeter of mercury (mmHg). Systolic blood pressure (SBP) was recorded at the appearance of the first Korotkoff sound and the diastolic blood pressure (DBP) at the disappearance of the fifth Korotkoff sound. The mean value obtained from three readings was used in the analysis. Hypertension was defined according to WHO criteria as SBP > 140mmHg and/or DBP>90 mmHg and /or the use of antihypertensive medication (12). Fasting blood venous samples were collected from all participants for determination of lipid profile.

Smoking habits were classified in terms of current smoker, exsmoker and non-smoker. A current smoker was defined as one who regularly smoked at least one cigarette per day, an ex-smoker was one who has given up smoking for at least 6 months, and non-smoker was one who has never smoked regularly. Patients were classified as physically active if they reported participating in walking for more than 30min/day.

Chi-square tests were performed to test for differences in proportions of categorical variables between two or more groups. The level p<0.05 was considered as the cut-off value for significance.


Socio-demographic characteristics of the studied diabetic patients showed that of the studied diabetic patients, 50.25% were males and 49.75% were females. Majority of the diabetic patients were in the age group (50-59) years old. A significant difference was observed between males and females in terms of age-group (p = 0.006), monthly income (p = 0.000001), education level (p = 0.0006) and occupation (p = 0.0000001) (Table/Fig 1).

When comparison in sleeping quality in studied subjects was done using Epworth sleepiness scale (ESS) it was found that female diabetic patients had significantly high chances of falling asleep during the day time than men; in terms of watching TV (p = 0.00008), passenger in car (p = 0.0001), lying down to rest in afternoon (p = 0.019), sitting & talking (p = 0.027) and car stopped in traffic (p = 0.00001). However, there exists an insignificant difference between males & females in terms of falling sleep during daytime while sitting and reading (p = 0.206), sitting inactive in public place (p = 0.109), sitting quietly after lunch (p = 0.28) and in ESS score results (p = 0.245) (Table/Fig 2).

Sleeping quality, excessive day time sleepiness and its patterns in the diabetic population using the PSQI showed that sleep loss was high in diabetic patients (35%).Most of the diabetic patients with sleep disturbances experienced that they cannot get sleep within 30 min (p = 0.002) and had to get up to use the bathroom (p = 0.0000001) as compared to their counterparts with good sleep (Table/Fig 3).

Baseline characteristics and risk factors for diabetes according to sleeping status and gender using Epworth Sleepiness Scale (ESS) score revealed that 35% of the diabetic patients were very sleepy during the day time with 49% males and 50% females. Obesity was significantly higher in diabetic women who had higher level of daytime sleepiness than men (p = 0.00005). Physical activity was significantly lower in diabetic women with daytime sleepiness compared to men (p = 0.001) but there was no significant differenceas far as risk factors like hypertension, high cholesterol and kidney diseases are concerned, in both males and females with daytime sleepiness (Table/Fig 4).


Type-2 Diabetes accounts for approximately 90% of all diabetes cases worldwide. Diabetes may lead to a number of serious health complications like diabetic retinopathy, cardiovascular disease, kidney failure, neuropathy and diabetic foot disease. In addition to these serious health concerns, a recent study reports that diabetes may negatively affect sleep. Relationship between sleep disorders and diabetes mellitus is less understood and less studied in state of Punjab. The current study is one of the few studies using the Epworth sleepiness scale (ESS) and Pittsburgh sleep quality index (PSQI) to examine the daytime sleepiness and quality of sleep in the diabetic population. The present study showed that there was a strong association between daytime sleepiness and diabetes. This finding suggests that diabetes should be considered whenever a complaint of daytime sleepiness is present in individuals.

The results of the study have demonstrated a sleep loss of 35% in Punjabi diabetic population residing in Punjab. Among the studied diabetic patients female diabetic patients (50%) were likely to have more sleep loss than male (49%) .It was reported in a study byBener et al (13). (2010) that disturbed sleep was more prevalent in diabetic population with evidence of sleep loss varying significantly by gender in diabetic patients and more sleep loss was observed in females. In a study conducted by Raman et al (14) (2010) it was found that the prevalence of abnormal sleep pattern was more in subjects with diabetes than with those without diabetes especially in women. Likewise, the prevalence of short duration of sleep was higher in subjects with diabetes compared to those without diabetes. Women subjects with ASP had a higher risk of diabetic neuropathy on both univariate and multivariate analysis. On the contrary, a study by Mallon et al (15) (2005) reported an association between sleep disturbances and diabetes was probably easier to demonstrate in men.

In this present study ,diabetic patients (35%) reported high chances of daytime sleepiness .In a study conducted by Sridhar and Madhu (8) (1994) the prevalence of sleep disturbances in 184 persons with diabetes, and 99 controls matched for age and sex was studied and it was found that sleep disorders were more common in diabetics Patients with sleep disturbances were younger than those with normal sleep, and had onset of diabetes at a younger age. Quality of life was affected and coping with the disease was made difficult by sleep disorders. In another study conducted by Trento et al (16) (2008), it was evaluated that sleep duration and quality was in relation to glycemic control in patients with type-2 diabetes. These findings suggest that type-2 diabetes is associated with sleep disruptions even in the absence of complications or obesity.

Another study done in Japan among male population, Kawakami et al (17) (2004) reported a high incidence of diabetes in male subjects reporting sleeping disturbances after controlling for other factors relevant to type-2DM. These studies identify sleep as a potential factor influencing glucose control in a specific population of patients with type-2 DM.

In this study, quality of sleep varied substantially by gender in diabetic patients. A significant difference was observed between males and females in terms falling asleep during the daytime while watching TV (p = 0.00008), as a passenger in car for an hour without a break (p = 0.0001), lying down to rest in the afternoon when circumstances permit (p = 0.019), sitting and talking to someone (p = 0.027) and in a car, while stopped for a few minutes in traffic(p = 0.00001). However there existed an insignificant difference between males and females in terms of daytime sleepiness while sitting and reading (0.206), sitting inactive in a public place like a theatre or meeting, sitting quietly after lunch without alcohol (0.28) and in ESS score results (p = 0.245). This is in contrast to another study (13) in which significant difference was observed in ESS score between both genders. Study conducted by Luyster and Dunbar- Jacob (18) (2001) showed that 55% of participants were poor sleepers according to PSQI. Poor sleep quality was associated with worse diabetes. Poor sleep is common in type-2 diabetes and may adversely impact quality of life. Thus, poor diabetes control could contribute both to a higher perceived sleep debt and lower sleep quality.

In the present study, there was a significant association found between poor sleep and different co-morbid factors. Obesity was significantly higher in diabetic women with high chances of falling asleep during the day as compared to men (p = 0.00005). This result supports the study finding of another study that sleep disorders correlates highly with obesity in diabetic population (13). Physical activity was significantly less in women as compared to men (p = 0.001). Increase in sleep loss among diabetic women could be because of high occurrence of obesity and less physical activity. It was also reported in a study that (13) women with sleep disturbances were more likely to be obese, and less likely to be physically active. Co-morbid factors like hypertension, high cholesterol and kidney disease did not have significant difference between male and female with excessive daytime sleepiness A strong association also exists between obesity, impaired glucose tolerance, insulin resistance and sleep loss.


It was observed in the present study that disturbed sleep was more prevalent in the diabetic population. Also, daytime sleepiness was observed more in diabetic patients, especially in women. Sleep loss varied according to gender in diabetic patients. A nonsignificant difference was observed in ESS scores between both genders. Obesity was more common among diabetic women with poor sleep than men, and also physical activity was significantly less in women compared to men.


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