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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
Case report
Full Version
Plasmapheresis as an Adjunctive Therapy for Yellow Phosphorus Poisoning: A Case Report
Correspondence Address :
Brian William Dmello,
Junior Resident, Department of Emergency Medicine, St. John’s Medical College Hospital, Sarjapur Road, Koramangala, Bengaluru-560034, Karnataka, India.
E-mail: brian03011992@gmail.com
Yellow Phosphorus (YP) poisoning is an infrequent, yet severe medical condition characterised by multi-systemic toxicity. The ingestion or inhalation of YP can lead to gastrointestinal irritation, hepatic injury, and Acute Liver Failure (ALF). Plasmapheresis, a therapeutic intervention involving the removal and replacement of plasma components, is a potential adjunctive treatment for YP poisoning. This case report aims to explore the mechanistic rationale, clinical efficacy, and safety considerations of plasmapheresis in the management of this toxicological emergency. Here, a 16-year-old female reported to the Emergency Department (ED), having consumed 1-2 g of Ratol poison at two different times of the day. She came to the hospital on day 4 post-consumption. On admission, the patient was jaundiced and Arterial Blood Gas (ABG) analysis was suggestive of respiratory alkalosis with hypokalemia. Treatment focused on fluid therapy, vitamin K therapy, and N-Acetyl Cysteine (NAC). She developed angioedema and urticaria with no airway compromise, in response to intravenous NAC. A diagnosis of acute liver injury secondary to YP poisoning was made. Close monitoring of liver function and coagulation parameters, and bleeding complications was done. Plasmapheresis was considered as NAC reinitiating was not feasible due to potential anaphylaxis. The patient responded well to the treatment and was discharged on day 7 of hospitalisation.
Acute liver injury, N-acetyl cysteine, Ratol poison
A 16-year-old female presented to the Emergency Department (ED) after ingesting 1-2 g paste of undiluted Ratol poison (Zinc Phosphide containing 3% YP) twice within the same day (Total of 2-4g). She developed diffuse abdominal pain, profuse vomiting, and constipation on day 2. Her initial management at a local hospital involved conservative treatment with intravenous fluids, vitamin K, and N-Acetyl-Cysteine (NAC). Investigations revealed abnormal Liver Function Test (LFT) (transaminitis) and coagulation profile abnormalities on day 3. Due to deteriorating LFT and coagulation profile (Table/Fig 1), she was referred to the hospital (day four post-consumption). Upon admission, the patient was haemodynamically stable, febrile and jaundiced. Systemic Examination including Central Nervous System (CNS) examination was normal. Stat Blood glucose values were normal, Arterial Blood Gas (ABG) analysis was suggestive of respiratory alkalosis with hypokalemia (Table/Fig 2).
Other routine investigations like Electrocardiogram (ECG), Chest X-Ray (CXR), Screening ECHO and Ultrasonography (USG) of the abdomen were normal. Treatment continued along similar principles, focusing on fluid therapy, vitamin K, and NAC.
Additionally, prophylactic antibiotics and anti-encephalopathy measures (Syrup Lactulose TID and Tab Rifaximin BD) were initiated. However, she developed angioedema and urticaria (no airway compromise) in response to intravenous NAC, which resolved with hydrocortisone, pheniramine maleate and discontinuation of therapy. A diagnosis of acute liver injury secondary to Yellow Phosphorus (YP) poisoning and adverse drug reaction to NAC was made. Hospitalisation ensued to monitor anaphylaxis, closely assess liver function and coagulation parameters, prevent acute fulminant liver failure and manage bleeding complications. The patient’s Model for End-Stage Liver Disease (MELD) score on the day of arrival was 29, which progressed to 33 on day 1. Deteriorating coagulation profile over subsequent days necessitated Fresh Frozen Plasma (FFP) transfusions (4 Units). Plasmapheresis was considered as NAC reinitiating was not feasible due to potential anaphylaxis. The procedure involved a Plasma Exchange (PLEX) volume of 2.6 L {2.4 L FFP+0.2 L Normal Saline (NS)}, using 14 units of FFP with heparin and additional calcium supplementation after every 3-4 units of FFP. The patient tolerated the procedure well; her symptoms were managed conservatively, and subsequent measurements demonstrated gradual improvement in LFT and International Normalised Ratio (INR) over a week. The patient’s condition improved, oral feeds were initiated on day 5, suitable consults were obtained, and she was discharged on day 7 of hospitalisation.
Yellow Phosphorus is a waxy, yellowish, crystalline solid with wide-ranging industrial applications, including the manufacturing of tracer bullets, incendiaries, semiconductor additives, fertiliser derivatives and fireworks (Asia and Latin America). It is commonly used as an insecticide and rodenticide and even finds application in homoeopathic medicine (1). YP among adults is predominantly ingested with the intention of deliberate self-harm [2,3]. However, as rodenticide tubes (containing YP) resemble toothpaste, they may be accidentally ingested in the paediatric population.
Absorption of YP occurs predominantly through the Gastrointestinal (GI) tract but can also happen via the respiratory tract, skin, and mucous membranes, following which it is evenly incorporated into various tissues. The liver is the primary site of distribution due to its first-pass metabolism (4).
YP acts as a fat-soluble protoplasmic poison and a potent hepatotoxin, leading to severe tissue hypoxia by generating phosphine gas that inhibits cytochrome C oxidase and oxidative metabolism (5). The exact mechanism of toxicity remains largely unknown; however, it is believed to alter ribosomal function, protein synthesis (6), blood glucose regulation, glycogen deposits (7), lipoprotein and triglyceride synthesis. Consequently, intracellular accumulation and fatty degeneration of organs such as the liver, kidney, heart, and brain can also occur [8,9]. The central nervous, cardiovascular, haematological, renal, and hepatobiliary systems are particularly susceptible to hypoxic injury, with progression to shock and cardiovascular collapse. Even small amounts of YP can cause profound multiorgan dysfunction and death, although the usual fatal dose is 60 mg (1 mg/kg body weight).
The progression of YP poisoning has been categorised into three distinct clinical stages (10). Stage 1- <24 hours of ingestion, symptoms reflective of GI irritation occur due to the development of phosphine gas upon contact between phosphorus and hydrochloric acid in the stomach.
Stage 2 (1-3 days), patients may remain asymptomatic, but liver enzyme and bilirubin levels deteriorate due to toxic hepatitis.
Stage 3 (>72 hours) Acute Liver Failure (ALF) can manifest, accompanied by coagulopathy, encephalopathy, arrhythmias, Acute Renal Failure/Acute Kidney Injury (ARF/AKI), and haemodynamic instability. Recovery or death can occur at this stage. The symptoms manifested by the patient in the present case report were consistent with the known pharmacological effects of YP.
This patient also exhibited lower total counts (bone marrow toxicity) and hypocalcaemia consistent with YP poisoning due to the preferential binding of calcium by phosphorus in serum (11). YP causes necrobiosis of the liver (12), manifesting as ALF with deranged LFTs and coagulopathy as the most common presentation (13), clinically ranging from mild transaminitis to fulminant liver failure.
NAC, conventionally used for paracetamol poisoning due to its antioxidant and hepatoprotective properties, has been studied in cases of ALF (14),(15). Its effectiveness in rodenticide-induced ALF is still under investigation, showing promising results in some and questionable benefit in others (16). A recent study conducted in the Indian sub-population suggest that NAC may be beneficial if initiated early in YP intoxication, with delays in initiation linked to higher mortality (17). One possible mechanism is NAC’s role in lowering von Willebrand Factor (vWF) levels in the blood, which is elevated in YP poisoning. Anaphylactoid reactions to intravenous NAC have been extensively documented (18),(19), which are rarely fatal but generally non-life threatening and easily treatable. A similar anaphylactoid reaction was observed in the present patient and was amenable to conventional treatment (20),(21). Other treatment modalities include corticosteroids have been used and found to be ineffective and potentially harmful in YP poisoning, and the combination of corticosteroids and exchange transfusion did not prevent coma progression or reduce mortality rates (22).
Poisoning with YP presents a significant challenge in terms of effective treatment options. Recent Liver Transplant Society of India (LTSI) guidelines focus on urgent liver transplantation to treat rodenticide hepatotoxicity (23). While a liver transplant remains the definitive therapy in YP poisoning and has been implemented in select cases of ALF (24), including in an Indian setting, high cost and limited availability render it inaccessible to many patients (25). Moreover, the scarcity of liver donors exacerbates this issue. Hence, developing countries focus on maximising patient survival with nontransplant treatments. Alternatively, Continuous Renal Replacement Therapy (CRRT) and Therapeutic Plasma Exchange (TPE) have demonstrated some promise in paediatric YP poisoning cases (26), but their affordability remains a barrier to widespread implementation. TPE is the removal of a patient’s plasma and replacement of it with plasma from a donor along with a colloid using an extracorporeal device.
Although PLEX transfusions in acute YP intoxication were described as early as 1971, the landmark study by Larsen FS et al., introduced the first open randomised controlled trial of PLEX for ALF, leading to the incorporation of plasmapheresis into the therapeutic options for ALF (27). Before this publication, existing studies on PLEX in liver failure primarily consisted of retrospective case series or cohort studies, exhibiting considerable variability in the protocols employed. The 2019 guidelines from the American Society for Apheresis (ASFA) establish High-Volume Plasma Exchange (HV-PLEX) as the preferred first-line treatment for ALF, either as a standalone therapy or in combination with other modalities (category 1 indication) (28). HV-PLEX has received Level I, Grade 1 recommendation in the European guidelines as well as in Asia-Pacific guidelines (29) for ALF management, attributed to its proposed mechanism of removing plasma cytokines and drivers of the systemic inflammatory cascade and an added advantage of providing deficient clotting factors and albumin. Emerging evidence also suggests the efficacy of standard-volume PLEX (SV-PLEX) (30) and low-volume PLEX (LV-PLEX) in ALF management (31).
Plasmapheresis thus emerges as a potential therapeutic modality, serving either as a standalone treatment or as a bridge to liver transplantation in YP poisoning, thereby enhancing survival rates. Early elevations in transaminase and ALP, a >10-fold increase in ALT, severe PT derangement, metabolic acidosis, and hypoglycaemia predict poor prognosis. At the same time, the latter two are significantly associated with mortality. Several studies attest to PLEX showing therapeutic benefits in YP poisoning in improving transplant-free survival, (32) reducing total bilirubin, SGOT, INR, Total Leucocyte Count (TLC) ammonia, Sequential Organ Failure Assessment (SOFA) and MELD Na score (33),(34) albeit with some caveats like the amount consumed and time to initiation from consumption (35). The discrepancy also exists with regard to protocol deployed, the number of sessions required (36), and the type of PLEX therapy to be used- with all, LV-PLEX, SV-PLEX and high volume PLEX (HV-PLEX) showing considerable success in YP poisoning. The authors deployed SV-PLEX for the patient with considerable success.
Previously, the management of YP poisoning had remained mainly supportive, with the accepted definitive management being liver transplantation among those who developed ALF. Emerging evidence suggests that plasmapheresis is beneficial when initiated early and prevents the necessity for a liver transplant in ALF.
DOI: 10.7860/JCDR/2024/65523.19445
Date of Submission: May 19, 2023
Date of Peer Review: Jun 17, 2023
Date of Acceptance: Dec 02, 2023
Date of Publishing: May 01, 2024
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: May 20, 2023
• Manual Googling: Nov 27, 2023
• iThenticate Software: Nov 30, 2023 (7%)
ETYMOLOGY: Author Origin
EMENDATIONS: 6
- Emerging Sources Citation Index (Web of Science, thomsonreuters)
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