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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)
E-mail: drrajendrak1@rediffmail.com
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.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
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
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Comparison of CT-Determined Pulmonary Artery Diameter among Smokers and Non-smokers: A Cross-sectional Study
Correspondence Address :
Shashi Kumar Shetty,
Assistant Professor, Department of Medical Imaging Technology, Nitte (Deemed to be University), KS Hegde Medical Academy, Deralakatte, Mangalore-575018, Karnataka, India.
E-mail: shettyshashi.research@gmail.com
Introduction: Tobacco smoking is a common addiction in our society. The toxic chemical compounds present in tobacco smoke cause epithelial damage and inflammation of the airways. Chronic smoking results in the thickening of the pulmonary arterial wall and vasoconstriction, leading to the development of pulmonary arterial hypertension. Hence, measurement of pulmonary artery diameter using Contrast Enhanced Computed Tomography (CECT) may be helpful in the early detection of pulmonary arterial hypertension.
Aim: To compare the diameters of the Main Pulmonary Artery (MPA), Right Pulmonary Artery (RPA), and Left Pulmonary Artery (LPA) using CECT thorax in smokers and non-smokers.
Materials and Methods: A cross-sectional study was conducted from April 2021 to March 2022 in the department of radio-diagnosis, KS Hegde Hospital, Karnataka, India, consisting of 100 patients referred for CECT thorax in the age group of 18-85 years. They were divided into two groups: smokers and non-smokers, with 50 patients in each group. They were further categorised into three age groups: < 50 years, 50-60 years, and >60 years. The widest diameters of the MPA were measured at the level of bifurcation of the artery and perpendicular to the long axis of the artery. At this level, RPA and LPA diameters were measured at the widest portion on 1.25 mm axial images of the arterial phase. Variation in the pulmonary artery diameter was compared between smokers and non-smokers with respect to age and analysed by unpaired t-test and Pearson correlation.
Results: Diameters of MPA, RPA, and LPA were statistically significant (p<0.05) in smokers compared to non-smokers. In smokers, MPA and RPA diameters correlated with age, which was statistically significant (p<0.05). No significant correlation (p>0.05) was shown between age and MPA, RPA, and LPA diameter in non-smokers. The mean MPA diameter showed a significant difference (p<0.05) in all three age groups.
Conclusion: The diameter of the pulmonary artery is statistically significant in smokers compared to non-smokers. Hence, assessment of pulmonary artery diameters among smokers using CECT thorax will help to diagnose Pulmonary Hypertension (PH) at an early stage.
Contrast enhanced computed tomography, Left pulmonary artery, Main pulmonary artery, Pulmonary hypertension, Right pulmonary artery
The lungs play an essential role in the exchange of gases. Their primary function is to supply oxygen to the blood and remove carbon dioxide from the blood. There are three levels of barriers that protect the lungs from harmful chemicals. The nose serves as the first barrier system, consisting of cilia and hair follicles, which does not allow large particles from entering. The second barrier is coughing, which helps remove any inhaled particles. The third barrier consists of the epithelial lining on the surface of the airway, which helps prevent infections (1).
One of the common addictions in our society is smoking. Smoking consists of toxic chemical compounds that are carcinogenic and cause epithelial damage and inflammation of the airways (2). Lung damage increases with the number of cigarettes smoked (3). Smokers’ life expectancy is 14 years lower compared to non-smokers (4). Developing countries show higher rates of cancer and patient deaths related to smoking compared to developed countries. Tobacco smoking is one of the leading causes of death in developing countries (5).
Smoking leads to airway inflammation and thickening of the pulmonary arterial wall (6). Some studies have shown that tobacco smoke causes elevated expressions of the vascular endothelial growth factor and suppresses the endothelial nitric oxide synthase in the pulmonary artery (7),(8). This leads to an increase in circulating endothelin, leading to pulmonary arterial vasoconstriction and PH (9),(10).
Examination and visualisation of the pulmonary artery can be performed using various non-invasive imaging techniques such as chest radiography, Magnetic Resonance Imaging (MRI), and Computed Tomography (CT). Pulmonary artery enlargement may be caused by PH, leading to right heart failure and enlargement. Patients with lung diseases may exhibit enlarged pulmonary arteries (11),(12). Pulmonary artery enlargement can be visualised in a chest X-ray. However, CT and MRI play a vital role in measuring pulmonary artery size, as there is no overlap with mediastinal and hilar organs (13). In PH, the mean pulmonary artery pressure is more than 25 mm Hg at rest and more than 30 mm Hg during exercise. If the pulmonary artery diameter is more than 29 mm in a CT scan, it may indicate PH (14).
In this study, the author aimed to address the assessment of pulmonary artery diameters among smokers using CECT thorax. This study will be helpful in diagnosing PH at an early stage by comparing the diameters of the MPA, RPA, and LPA on CECT thorax in smokers and non-smokers.
A cross-sectional study was conducted from April 2021 to March 2022 in the Department of Radiodiagnosis at Justice KS Hegde Charitable Hospital, Mangalore, Karnataka, India. The study was approved by the Institutional Ethical Committee (INST.EC/EC/101/2021-22). It included a total of 100 patients aged between 18 and 85 years who were referred for a CECT thorax scan.
Sample size calculation: A random sampling method was used. At a 5% level of significance and 80% power, the required sample size per group was 50. Patients who were currently active smokers and had a smoking history of minimum one year were categorised as smokers. Individuals who had never smoked were categorised as non-smokers. They were further categorised into three age groups: <50 years, 50-60 years, and >60 years.
Inclusion criteria: Those patients aged between 18 and 85 years with a smoking history of minimum one year were included in the study.
Exclusion criteria: Those Patients with structural cardiac diseases, diagnosed cases of PH, pulmonary thromboembolism, and lung fibrosis due to various reasons were excluded from the study.
Procedure
Scans were performed on the GE Revolution Evo (128-slice multidetector CT). Non-ionic iodinated contrast of 60-80 mL was given intravenously at a flow rate of 3 mL per second. Routine scan parameters including cranio-caudal scan direction, 5 mm slice thickness, and 5 mm slice increment were maintained for each scan. The diameters of the MPA, RPA, and LPA were measured separately in all three groups, including smokers and non-smokers (Table/Fig 1). The widest diameter of the MPA was measured at the level of the artery’s bifurcation and perpendicular to the artery’s long axis. At this level, the RPA and LPA appeared to be of equal sizes. The diameters of the RPA and LPA were measured at their widest portions on 1.25 mm axial images of the arterial phase. All measurements were conducted using the reformat tools of the CT machine.
Statistical Analysis
The variation in pulmonary artery diameter was compared between smokers and non-smokers with respect to age and analysed using an unpaired t-test and Pearson correlation. The data were expressed as mean ± standard deviation. A p-value <0.05 was considered statistically significant. The Pearson correlation coefficients was used to assess the correlation of MPA, RPA, and LPA diameters with age in both smokers and non-smokers. The statistical analysis was conducted using Statistical Package for Social Sciences (SPSS) software version 2.0.
In this study, 100 patients were included and all were males. An unpaired t-test was used to compare the mean age between smokers and non-smokers, revealing a mean age in smokers of 58.74±12.565 mm and 53.54±14.442 mm in non-smokers. No significant difference (p>0.05) was found in mean age between smokers and non-smokers. However, a significant difference was noted in MPA diameter in smokers and non-smokers with p<0.001. The mean LPA diameter in the smokers and non-smokers group was 17.5200±3.54585 mm and 15.7920±1.96716 mm, respectively, with a significant difference noted in LPA diameter in smokers and non-smokers with p<0.05 (Table/Fig 2).
The comparison of pulmonary artery diameters in smokers and non-smokers under each age group was done by unpaired t-test. In the age group of <50 years, which included 10 patients in the smokers group and 17 patients in the non-smokers group, a significant difference (p<0.05) was observed in mean MPA diameter, RPA diameter, and LPA diameter (Table/Fig 3).
In the 50-60 years age group, which included 17 patients in both smokers and non-smokers group, a significant difference (p<0.05) was found in mean MPA diameter between smokers and non-smokers, while no significant difference (p>0.05) was found in RPA and LPA diameters (Table/Fig 4).
In the >60 years age group, which comprised 23 patients in the smokers group and 16 patients in the non-smokers group, a significant difference (p<0.05) was observed in mean MPA, RPA, and LPA diameters between smokers and non-smokers (Table/Fig 5).
Additionally, there was a positive correlation (p<0.001) between age and MPA diameter, as well as age and RPA diameter (p<0.05). However, there was no significant correlation (p>0.05) between age and LPA diameter in smokers (Table/Fig 6).
Lastly, there was no significant correlation (p>0.05) between age and MPA diameter, age and RPA diameter, or age and LPA diameter among non-smokers (Table/Fig 7).
Early detection of Pulmonary Hypertension (PH) may be achieved by measuring the pulmonary artery diameters in smokers undergoing CECT thorax. While a chest X-ray can visualise pulmonary artery enlargement, CT imaging is a more effective modality for measuring pulmonary artery size (13).
In this study, maximum number of cases in smokers (46%) was seen in the age group of >60 years. Smokers above 60 years of age showed a mean Main Pulmonary Artery (MPA) diameter of 34.03 mm. In an analysis by Steiger D et al., they enrolled 1949 smokers (15). Patients aged ≥55 years surpassed the MPA ≥34 mm cut-off. Comparable results were found in the present study. Their study revealed that advancing age affected the diameter of the ascending aorta more than the MPA diameter.
The authors in this study found a significant difference (p<0.001) in MPA diameter between smokers and non-smokers. In a study by Lee SH et al., involving 2547 individuals with diverse clinical conditions like smoking history, diabetes, obesity, hypertension, and obstructive lung disease, and another group of 813 healthy individuals, a significant difference was found (p<0.001) in the mean MPA diameter between smokers and non-smokers (16). They found the mean MPA diameter in smokers was 26.9±3.4 mm and in non-smokers was 26.4±3.4 mm. They also discovered a significant correlation (p<0.001) between age and MPA diameter in the group with diverse clinical conditions. In our analysis, a significant correlation (p<0.001) was found between age and MPA diameter in smokers. The authors also found a significant correlation (p<0.05) between age and Right Pulmonary Artery (RPA) diameter, but no significant correlation (p>0.05) between age and Left Pulmonary Artery (LPA) diameter in smokers. They found that in diverse clinical conditions, the mean MPA diameter in males was 27±3.4 mm and in females was 26±3.4 mm.
In this study, the mean MPA diameters in non-smokers within the age groups <50, 50-60, and >60 years were 25.612 mm, 25.165 mm, and 26.488 mm, respectively. Similar findings were reported in a study conducted by Lee SH et al., (16), where 813 healthy individuals (187 men and 626 women) were divided into age groups <45, 45-54, and ≥55. The mean MPA diameter for males in these age groups was 26 mm, 27 mm, and 26.3 mm, respectively, which closely aligns with our study. For females, the mean MPA diameter in these age groups was 24.4 mm, 25.4 mm, and 27 mm, respectively. They also noted a significant correlation (p<0.001) between age and MPA diameter, mentioning that advancing age affected the diameter of the ascending aorta more than that of the MPA diameter. The present study did not find a significant correlation (p>0.05) between MPA, RPA, and LPA diameters with age in non-smokers.
This study found a significant correlation between MPA (p<0.001) and RPA (p<0.05) diameter with age in smokers. However, no significant correlation (p>0.05) was found between age and LPA diameter in smokers. In a study by Chung KS et al., involving 226 COPD patients with ≥10 pack years of smoking, they observed a significant correlation (p<0.05) between age and body surface area with MPA diameter (17).
In this study, the mean diameters of the MPA in non-smokers were 25.740±2.65 mm, RPA 14.828±2.5256 mm, and LPA diameter 15.792±1.967 mm, respectively. A survey by Bozlar U et al., involving 126 normal patients in the age group of 19-46 years, found the mean diameters of MPA to be 24±2.8 mm, RPA 16.1±1.9 mm, and LPA 18.2±2 mm (18). They found that the mean LPA diameter was greater than the RPA diameter, similar to the present study. Additionally, the authors did not find a significant correlation (p>0.05) in non-smokers between age and MPA, RPA, and LPA diameters. However, Bozlar U et al., found a significant correlation (p<0.05) between age and RPA and LPA diameters, but no significant correlation (p>0.05) was found between age and MPA diameter. They also found a significant correlation (p<0.05) between MPA diameter, weight, and Body Mass Index (BMI). Furthermore, there was a significant correlation (p<0.05) of BMI with RPA and LPA diameter.
In their study, the mean MPA diameter in males was 24.3±2.5 mm and in females was 23.3±3.6 mm. The mean RPA diameter in males was 16.2±2 mm and in females was 15.6±1.6 mm. The mean LPA diameter in males was 18.4±2.1 mm and in females was 17.4±1.5 mm. Although the mean diameters were larger in males compared to females, there was no significant difference (p>0.05) in MPA and RPA diameter between males and females. Only the LPA diameter showed a significant difference (p<0.05) between males and females. In our study, the range of upper and lower limits of MPA diameter in non-smokers were 32.3 mm and 18.9 mm, RPA diameter 23 mm and 9 mm, and LPA diameter 19.6 mm and 9.6 mm. Almost similar results were seen in their study; the following range of upper and lower limits were observed: MPA diameter 29.5 mm and 18.5 mm, RPA diameter 19.8 mm and 12.4 mm, and LPA diameter 22.1 mm and 14.3 mm.
In this study, the mean MPA diameter in smokers was 31.906 mm±4.5259 mm. In a survey by De-Torres JP et al., involving 188 patients with COPD with ≥10 pack years of smoking (19), they found that the pulmonary artery diameter with pulmonary artery enlargement was 32.9±3.5 mm, and without pulmonary artery enlargement was 23.7±2.8 mm. Terzikhan N et al., performed cardiac CT on 2524 patients (20). The diameter of the pulmonary artery did not show much variation in current, former, and never smokers. The diameter was 26.0±3.9 mm in current smokers, 26.1±3.6 mm in former smokers, and 25.8±3.7 mm in never smokers. We found similar findings in the case of non-smokers, with a mean MPA diameter of 25.740±2.6562 mm. However, the MPA diameter in smokers was 31.906 mm±4.5259 mm.
Paul TK et al., performed a study on asymptomatic individuals in the Appalachian region (21). The mean MPA diameter in ever smokers was 26.33±4.22 mm, and in never smokers was 25.91±4.17 mm. They found that smoking history did not differ significantly. In contrast, the authors of present study found a significant difference (p<0.001) in the MPA diameter between smokers and non-smokers.
In this study, the mean MPA diameter in smokers was 31.906 mm±4.5259 mm, and in non-smokers was 25.740±2.6562 mm. Truong QA et al., studied asymptomatic individuals based on the Framingham Heart Study. They found the MPA diameter in smokers was 25.0±2.7 mm, in former smokers 25.1±3.0 mm, and in never smokers 25.2±2.8 mm (22).
Limitation(s)
The study population consisted only of males, as no female smokers were encountered during the study period based on the history taking. The authors in this study did not consider the duration and pack years of smoking. To fully comprehend the relationship between pulmonary artery diameters and the variables of sex, pack years of smoking, and BMI, further study is necessary. Cut-off values for pulmonary hypertension in smokers of different ages were not determined. However, to obtain accurate results, further research with larger sample sizes is required.
The diameters of the MPA, RPA, and LPA were larger in smokers compared to non-smokers, and this difference was statistically significant. There was a significant correlation between the mean MPA and RPA diameter according to age group in smokers. However, no significant correlation was observed in the mean LPA diameter according to age group in smokers. Furthermore, no significant correlation was found in the mean MPA, RPA, and LPA diameters according to age group in non-smokers. Therefore, assessing pulmonary artery diameters among smokers using CECT thorax might be helpful in diagnosing pulmonary hypertension at an early stage.
DOI: 10.7860/JCDR/2024/67227.19186
Date of Submission: Aug 25, 2023
Date of Peer Review: Nov 01, 2023
Date of Acceptance: Dec 08, 2023
Date of Publishing: Mar 01, 2024
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
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ETYMOLOGY: Author Origin
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