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

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Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
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Prof. Somashekhar Nimbalkar

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Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
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On Sep 2018




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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
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Muzaffarnagar Medical College,
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On Aug 2018




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"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,
Bengaluru.
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.
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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
Consultant
(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.
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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

Important Notice

Original article / research
Year : 2008 | Month : February | Volume : 2 | Issue : 1 | Page : 622 - 626

Ophthalmologic and Audiologic Problems In Beta Thalassemia Patients Treated With Prolonged Chelation therapy

ASVADI-KERMANI I, DOLATKHAN R,DIBAVAR M, KAZEMI AH, EIVAZEI ZIAEI J, SANAAT Z, FAKHARI A

Institution: Hematology and Oncology Research Center - Tabriz University of Medical Sciences. Shahid Ghazi Tabatabai Hospital.

Correspondence Address :
Roya Dolatkhah MD, Hematogy and Oncology Research Center - Tabriz University of Medical Sciences,Thalassemia and Hemophilia Center, Shahid Ghazi Tabatabai Hospital, Daneshghah Street, Tabriz,Iran
Tel:+98 (0)411 3361358 Fax:+98 (0)411 3343844. Email address: royadolatkhah@yahoo.com

Abstract

Background: The main aim of chelation therapy in iron overload is to achieve an iron balance and to prevent haemosiderosis. The objective of this study was to Determine visual and hearing problems in adults with beta major and Intermediate Thalassemia who received Desferrioxamine (DFO) as chelation.
Patients and Methods: Fifteen patients aged 16 to 63 years, who received DFO by intravenous and subcutaneous route on regular program, were evaluated for 5 years. Variables such as age, sex, serum ferritin, DFO dose and duration of treatment gathered by a researcher designed questionnaire. Patients were examined by ophthalmologist and otolaryngologist. Data was collected using specific questionnaire and analyzed by SPSS 11 software.
Results: The mean serum ferritin level was 2025ng/ml and the mean treatment dose of DFO was 45mg/kg/day, 4 or 5 times a week. VEP (Visual Evoked Potential) and ERG (Electro Retino Graphy) ophthalmologic tests were negative in all of the patients. Two patients (13.3%) presented with cataract, and 2 others (13.3%) showed moderate visual loss. A mild, bilateral, high-frequency hearing loss developed in one patient. There was no significant relation between the serum ferritin levels and these problems.
Conclusion: These findings show any significant statistical relation between visual andaudiologic abnormalities and the use of high dose DFO or lower serum ferritin levels in our cases, yet regular ophthalmologic and audiologic examinations are advised for all thalassemic patients.

Keywords

Desferrioxamine, Thalassemia, Ophthalmologic problems, Audiologic problems

Hearing loss is observed in a large percentage of patients during intensive DFO therapy. The defect is correlated with the total monthly dose of DFO received, and it is more frequent in younger patients with low serum ferritin levels. The hearing defect should be detected early, performing an audiogram at least yearly, or whenever symptoms, even subtle, are reported (1).

Cataract has developed in some Experimental animals treated with deferoxamin and have been reported on rare occasions in patients receiving deferoxamin. Before beginning treatment, patients should be checked for cataracts by an ophthalmologist. Thereafter they should have yearly ophthalmologic examinations (2).Patients who develop hearing and/or sight problems are generally advised to stop the use of DFO for a time, restarting treatment at a lower dose once complications improve or disappear (3).

Material and Methods

Fifteen patients affected with Beta-Thalassemia, who received chelating therapy were evaluated for 5 years. They received chelation therapy for their iron overload due to transfusions. The iron overload was controlled by serum levels of ferritin. The mean age range of the cases was 36.33 years (16-63 years old). About 60 % (9 cases) were female and 40 %( 6 cases) were male, of them 8 cases (53.3%) were major thalassemia and 7 cases (46.7%) had intermediate variant. They received DFO by intravenous and subcutaneous route on regular program. Questionnaires completed for each patient and variables as age, sex, serum ferritin levels, Desferrioxamine dose and duration of treatment and duration of transfusion gathered. All of the patients were referred to ophthalmologist and otolaryngologist. The ophthalmologist examined patients and evaluated them for: changes in the retinal pigmentation (Limbos or Sclera hyperpigementation), cataract, retinal vessel abnormalities and visual side effects of DFO, such as visual loss, loss of color vision, central scotoma, night blindness. The specific Ophthalmological and Otolaryngological tests including Electro Retino Graphy (ERG) and VEP (Visual Evoked Potential) tests also been checked for them. Otolaryngical examinations, Pure Tone Audiometry and Tempanometry were performed on the patients by an expert otolaryngologist. Sinuses, nose and larynx of the patients were examined too. They were asked for problems such as tinnitus, vertigo, and hearing Hearing changes depended on the times or places and deafness, SPSS11 software was used for data analysis. Results were considered significant when the P-value was less than 0.05.

Results

The results are summarized in (Table/Fig 1).The mean serum ferritin level was 2025ng/ml and the mean treatment dose of DFO was 40mg/kg/day, 4 or 5 times a week. The patient received on the average 16.06 years blood transfusion therapy and it was 10.86 years for DFO therapy. (Table/Fig 1)VEP and ERG tests were negative in all of the patients. Two cases (13.3%) presented Posterior Sub Capsular Cataract (PSCC), the cases had not senile cataract. Two others showed moderate visual loss that was improved after reduction of DFO dose. One of These patients had limbos and sclera hyper pigmentation too. There was no significant relation between DFO dose and presentation of cataract (P=0.495), visual loss (p=0.109) and hyper pigmentation (P=0.289).Also there was no correlation between Ophthalmologic problems and duration of DFO therapy or transfusion (Table/Fig 2).There was no significant correlation between serum ferritin level and presentation of cataract and visual loss (P=0.415 and P=0.130 respectively).

Furthermore, three cases (20 %) had chronic sinusitis (frontal and maxillary), because of the skeletal deformities, and 2 of them had moderate epistaxis, due to low platelet count. A mild bilateral high-frequency hearing loss developed in one patient (case no 8) who had abnormal audiogram with deficit mostly in high frequency range (4000-8000 Hz).This patient was on 50 mg/kg/dose DFO and by reduction of DFO dose to 30 mg/kg/dose, audiogram showed partial recovery. There was no significant correlation between the presentation of hearing loss, DFO dose (P=0.209), duration of DFO therapy (P=1.000) and duration of transfusion (P=0.912). The patients evaluated for 5 years. The patients' mean blood transfusion date was 16.06 years and for DFO therapy was 10.86 years.

Discussion

We studied 15 regular transfused patients who were chelated with DFO,they received packed red cell every 25 days, and DFO 45mg/kg/day, 4 or 5 times a week. Only 2 cases (13.3%) showed moderate visual loss and one (6.6%) had mild high frequency hearing loss. As a whole about 86.7% and 93.4% of the patients had not any visual and hearing abnormalities respectively. Likewise, Cohen (4), in a study in children hospital of Philadelphia noted that 94% of their patients had no evidence of drug induced visual or auditory abnormalities.

Abnormalities therapy with deferoxamin has been reported in higher frequency in previous studies, even through the patients received large doses of the chelating agents or who had only modest amount of excessive Iron (4). In contrast Karimi showed hearing loss in his patients which affected 44.7%in the right side and 41.8%in the left side (5). They also noted significant correlation between doses of drug given at each episode of DFO therapy and hearing loss (5). In our case hearing loss was dependent on the DFO and by reducing the dose it subsided but, there was no significant correlation between the dose of DFO and duration of therapy in all of patients (P=0.209, P=1.000).Like our results no correlation found between duration of DFO therapy and sensorioneural deficits, in same studies (5), but Gallant et al in a study, documented visual and auditory neurotoxicity in 42 of 86 patients with transfusion dependent anemia who were chelating daily with subcutaneous Deferoxamin (7). Auditory deterioration and improvement, demonstrated serially in individual patients receiving and not receiving deferoxamin, respectively, provided convincing evidence for a cause- and- effect relation between deferoxamin administration and ototoxicity (7).

However, patients who have diabetes mellitus or these are being treated with psychotropic drugs may also be at risk of developing such problems, even if they are receiving correct doses of DFO. It has been proved that these conditions increase the access of DFO to the central nervous system (3).These findings are concordant with our own, because those cases suffered from diabetes showed visual problems (as cataract) and hearing loss. In one study, 21 out of 104 patients (20.2%) presented with high frequency sensorineural hearing loss (SNHL), either unilateral or bilateral. No ototoxic factor, other than DFO, was present in any of the patients. Meanwhile patients with SNHL presented with relatively lower serum ferritin levels than those with normal hearing, however no statistically significant difference was observed (8).

Either we used low doses of DFO (20-50 mg/kg/dose), or because of the paucity of our cases (only 15 cases), it seems that other studies with more cases are necessary for clarifying all of these discrepancies.

Conclusion

The data implicates high-dose deferoxamin as a central factor in the pathogenesis of the neurotoxicity (visual symptoms, abnormal audiograms, or prolonged evoked potentials) (6).Thus, careful regulation of the deferoxamin dosage and regular ophthalmologic and audiologic examination is recommended every six months in those without problems and more frequently in young patients with normal serum ferritin values and in those with auditory dysfunction (7). A dose of 50 mg/kg is recommended in those without abnormalities. With mild toxicity, a reduction to 30 or 40 mg/kg per dose should result in a reversal of the abnormal results to normal within four weeks. Moderate abnormalities require a reduction of deferoxamin to 25 mg/kg/dose with careful monitoring (7). Thus we suggest periodical audiologic and retinal checkups and a low dosage of DFO (below 50 mg/kg/dose) given on at least 5-6 days a week for the prevention and prompt diagnosis of audiologic and ophthalmologic complications especially in adult patients. Because all of our patients have been referred from children hospital to our center, and beginning of their DFO was before of our study, their Pre DFO status was not clear for us. So a complete control studies for DFO therapy side effects must be done before beginning of DFO therapy.

References

1.
Borgna-Pignatti C.Galanetto R.,Thalassemias and related disorders.In:P.Greer J.,Foerster J.,N.Lukens J.,M.Rodgers G.,Paraskevas F.,Glader B.,Wintrobe's Clinical Hematology,11th edition. Lippincott Williams&Wilkins,2004;P:1339-1340
2.
C.Andrews N.,Disorders of iron metabolism.In:I.HandinR.,E.Lux S.,P.Stossel T.,Blood Principle and Practice of hematology,second edition.Lippincott Williams&Wilkins,2002;P:1424-1427
3.
Eleftheriou A. Iron overload and iron chelation,In:About thalassemia,Thalassemia International Federation Publication,2003;P:38-61
4.
Cohen A., Martin M,Mizanin J,konkle DF,Schwartz E,Vision and hearing during deferoxamine therapy.J Pediatr, 1990 Aug; 117(2Pt 1):326-30.
5.
Karimi M,Asadi-Pooya AA,Khademi B,asadi-pooya K,Yarmohammadi H,Evaluation of the incidence of sensorineural hearing loss in beta-thalassemia major patients under regular chelation therapy with desferoxamine.Acta Haematol.2002;108(2):79-83.
6.
Olivieri NF,Buncic JR,Chew E,Gallant T,Harrison RV,Keenan N,et al.Visual and audiory neurotoxicity in patients receiving subcutaneous deferoxamine infusions.N Engl J Med.1986 Apr 3;314(14):869-73
7.
Gallant T, Boyden MH, Gallant LA, Carley H, Freedman MH.Serial studies of auditory neurotoxicity in patients receiving deferoxamin therapy. Am J Med. 1987 Dec; 83(6):1085-90.
8.
Kontzoglou G,Koussi A,Economou M,tsatra I,Perifanis V,Noussios G et al,Longterm audiological evaluation of beta-thalassemia patients.Acta otorhinolaryngol Belg.2004;58(2):113-7

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